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BRES2016-013178-495 CALLE TAMPICO U� VOICE (760) 777-7125 LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7011 COMMUNITY DEVELOPMENT DEPARTMENT INSPECTIONS (760) 777-7153 BUILDING PERMIT Date: 5/6/2016 Application Number: BRES2016-0131 Owner: Property Address: 51662 EISENHOWER DR MARGARITA MRAZEK COSS APN: 773135008 50662 EISENHOWER Application Description: MARGARITA MRAZEK / REMO❑€L_______�, LA QUINTA, CA 92253 Property Zoning: � � f Application Valuation: $7,000.00 Applicant: L'•,i Q ontractor: MARGARITA MRAZEK COSS ARGARITA MRAZEK COSS 50662 EISENHOWER 0662 EISENHOWER LA QUINTA, CA 92253 CITY OF LA QUINTA QUINTA, CA 92253 (760)861-6180 Llc. No.: LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 {commencing with Section 7000) of Division 3 of the Business and Professions Code, and my License is in full force and effect. License Class: License No.: Date Contractor: OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a ermlt subjects the applicant to a clvEl penalty of not more than five hundred dollars I, as owner of the property, or my employees with wages as their sole o ensation, will do the work, and the structure Is not intended or offered for sale. { C.7044, Business and Professions Code: The contractors' State License Law does not apply to an owner of property who builds or Improves thereon, and who does the work himself or herself through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that or she did not build or Improve for the purpose of sale.). as owner of the property, am exclusively contracting with IIre nsed contractors to struct the project. (Sec. 7044, 0uslness and Professions Cade: The Contractors' State Icense Law does not apply to an owrier of property who bullds or improves thereon, arid who contracts for the rojects with a contractor(sl licensed pursuant to he Contractors' State License Law.). I am exempt under Sec.�.Cafocthis reason CONSTRULT) E D AGENCY I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name: Lender's WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier: Policy Number: _ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Applicant: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. APPLICANT ACKNOWLEDGEMENT IMPORTANT: Application is hereby made to the Building Official for a permit subject to the conditions and restrictions set forth on this application. 1. Each person upon whose behalf this application is made, each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this application , the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and employees for any act or omission related to the work being performed under or Following issuance of this permit. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. certify that I have read this appllcatign pd state that the above information is correct. I agree to comply with all city and cou t rdlnanees and state laws relating to building :onstruction, and hereby authorize repr se t tfves of this city to enter upon the above -mentioned property for ins&Cti❑ s. DESCRIPTION FINANCIAL INFORMATION ACCOUNT CITY AMOUNT PAID PAID DATE BSAS SB1473 FEE 101-0000-20306 0 $1.00 $1.00 5/6/16 PAID BY METHOD RECEIPT # CHECK # CLTD BY MARGARITA MRAZEK COSS CHECK R15314 1037 RSE Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00 $1.00 DESCRIPTION ACCOUNT CITY AMOUNT PAID PAID DATE RESIDENTIAL, FIRST 1,000SF 101-0000-42403 0 $145.03 $145.03 5/6/16 PAID BY METHOD RECEIPT # CHECK # CLTD BY MARGARITA MRAZEK COSS CHECK R15314 1037 RSE DESCRIPTION ACCOUNT CITY AMOUNT PAID PAID DATE RESIDENTIAL, FIRST 1,000SF, PC 101-0000-42600 0 $47.86 $47.86 5/6/16 PAID BY METHOD RECEIPT # CHECK # CLTD BY MARGARITA MRAZEK COSS CHECK R15314 1037 RSE Total Paid for ELECTRICAL - NEW CONSTRUCTION: $192.89 $192..89 DESCRIPTION ACCOUNT CITY AMOUNT PAID PAID DATE APPLIANCE REPAIR/ALTERATION 101-0000-42402 0 $12.09 $12.09 5/6/16 PAID BY METHOD RECEIPT # CHECK # CLTD BY MARGARITA MRAZEK COSS CHECK R15314 1037 RSE DESCRIPTION ACCOUNT CITY AMOUNT PAID PAID DATE APPLIANCE REPAIR/ALTERATION PC 101-0000-42600 0 $4.83 $4.83 5/6/16 PAID BY METHOD RECEIPT # CHECK # CLTD BY MARGARITA MRAZEK COSS CHECK R15314 1037 RSE DESCRIPTION ACCOUNT CITY AMOUNT PAID PAID DATE VENT FAN 101-0000-42402 0 $24.18 $24.18 5/6/16 PAID BY METHOD RECEIPT # CHECK # CLTD BY MARGARITA MRAZEK COSS CHECK R15314 1037 RSE DESCRIPTION ACCOUNT CITY AMOUNT PAID PAID DATE VENT FAN PC 101-0000-42600 0 $9.66 $9.66 5/6/16 PAID BY METHOD RECEIPT # CHECK # CLTD BY MARGARITA MRAZEK COSS CHECK R15314 1037 RSE Total Paid for MECHANICAL: $50.76 $50.76 DESCRIPTION ACCOUNT CITY AMOUNT PAID PAID DATE FIXTURE/TRAP 101-0000-42401 0 $72.54 $72.54 5/6/16 PAID BY METHOD RECEIPT # CHECK # CLTD BY MARGARITA MRAZEK COSS CHECK R15314 1037 RSE DESCRIPTION ACCOUNT CITY AMOUNT PAID PAID DATE FIXTURE/TRAP PC 101-0000-42600 0, $72.54 $72.54 5/6/16 PAID BY METHOD RECEIPT # CHECK # CLTD BY MARGARITA MRAZEK COSS CHECK R15314 1037 RSE DESCRIPTION ACCOUNT CITY AMOUNT PAID PAID DATE WATER SYSTEM INST/ALT/REP 101-0000-42401 0 $12.09 $12.09 5/6/16 PAID BY METHOD RECEIPT # CHECK # CLTD BY MARGARITA MRAZEK COSS CHECK R15314 1037 RSE DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE WATER SYSTEM INST/ALT/REP PC 101-0000-42600 0 $12.09 $12.09 5/6/16 PAID BY METHOD RECEIPT # CHECK # CLTD BY MARGARITA MRAZEK COSS CHECK R15314 1037 RSE Total Paid for PLUMBING FEES: $169.26 $169.26 DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE REMODEL, FIRST 100 SF 101-0000-42400 0 $49.31 $49.31 5/6/16 PAID BY METHOD RECEIPT # CHECK # CLTD BY MARGARITA MRAZEK COSS CHECK R15314 1037 RSE DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE REMODEL, FIRST 500 SF PC 101-0000-42600 0 $134.88 $134.88 5/6/16 i PAID BY METHOD RECEIPT # CHECK # CLTD BY MARGARITA MRAZEK COSS CHECK R15314 1037 RSE Total Paid for REMODEL: $184.19 $184.19 DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE SMI - RESIDENTIAL 101-0000-20308 0 $0.91 $0.91 5/6/16 PAID BY METHOD RECEIPT # CHECK # CLTD BY MARGARITA MRAZEK COSS CHECK R15314 1037 RSE Total Paid for STRONG MOTION INSTRUMENTATION SMI: $0.91 $0.91 • t � j Ln aj CL a e ) < \ \ L E ƒ L 3 � § « k § j / ui k � � R m J � Im l « > - Z0- j = z = / § 5 / V) » § \ } § \ \ d c 0 2 \ 0 g 7 §LL as § t -i -iLLI N a ) k k o a) LLI 2 I � � § k L u � LLJ k k 2§ E I I � / � \ 8 \ 2 7§ 3 6 z § L a 2 a F- M R 3 zLLI 2 ELLJcc ® § § < u ca 2 2 � J 8 o q § ) § § b § 2 0 ƒ d \ § \ u 2 \ » e \ / 5 c / _ u _ 2 \ d \ 2 \ § a � LLI a LL k k k LO W �Lo Q G Q 2 ƒ m ƒ K k k rn E § § ~ ELM Q Q LU u u u � ® z z z � LU � � LU z z z k § to G k k § u u u he m be LU § § a § § § § z § § J cr cc ix § § § LLI w § § § E z k u 1. § m § LLI « m k LA 2 �§ � K � / � # u cm LU � u a / LU j � LU atD 2 tm 2 . � � @ 8 k 8 8 2 y4 .4 t k� « § § j k A Q § M k k § Ln § z § o M } � � 2 u L k k 41 k coe ■ a- _ G J m W In W In W In W to W In W In W In W In W In W 4A W In W In Y Y Y Y Y Y Y Y Y Y Y he W N W N W N W N W N W N W N W N W N W N W N W N a a a a a a a a a a a a oc ac o: oc cc cc oc m ALA �( �( �4A �( �t �( �L �t �t �t �Ln c a( � 0 aL � 0 at 1 0 a4 0 aL � 0 aIA 0 a( 0 a4 0 aL Q at 0 at 0 aLn o a m u m u u m u m u m u m u m u m u u m u m u a a a a a a a a a a a a (D c� D: cc a oc cc a cc oC a a a a a a a a a a a a C Q Y he le Y he ]d ]C Ne heY Y S U W u W u W U W u W U W u W u W u W u W u W u W y�j S U S u S u S u S u S u S u S u S u S u S u S u x be N N N N U W M O cm O M O M O M O M O M O M O M O M O M O M O S ei 'i ei ei ai ei ai ei ei ei ei e-I u W rn In M IA M IA M IA fn IA M Ill M IA rn IA M IA M IA rn IA M IA u W .i rI .-1 ri d. 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IA W !L a W Z cc LUWcc W d LL LL Z Oc G k- It Ir U J m L- 0 N lD 0 r ro 2 T f0 v LL } W J m kA U Y W N Q mN H Q 0 a � Q l7 ac Q G O Y = v F- w W = m u Y 1v (L M W O u a r' M W In u lz W OC w W aID c � o tO a LO a m m a4-1�. 4^ 00 0 J Q Mw- W a o & LA u "' H w W � C H m 0 0 c» Oki a Bin # City of 1a Quin to Building 8t Safety Division Permit # . 78-495 Calle Tampico La Quinta, CA 92253 - (760) 777-7012 �Us W lb- f) 1'�) Building Permit Application' and Tracking Sheet PMJdctAddress: Owner'sNamc: A(Z6Aa-T4 M e42L (< COES- A. P. Number: Address: -5 k6-2 —71C / u%v�= ,z Legal Description: City, ST, Zipi��A V 1f14 C4- 922-6-3 Contractor. Telephone:? ,, 0. Address: Project Description: ,5;�f�2()(f)-7-7 City; ST, Zip: Telephone: M State Lic. # : City Lie. #; Arch., Engr,., Designer: D %%C Or Address: 6-(/ City, ST, Zip: Telephone: P .-,,�F � v;a r, - �' Construction Type: Occupancy: ` s' State Lic. #`'•F :-;.•- F --- %` .•s:.u� >: �:��- :fi�;srp:��- �•%!�Pro ect tYPa (circle one): New Add'n Alter Repair Demo Me of Contact Persona l' I rL(� �� � Sq. Ft.: S # Stories: #Units: Telephone # of Contact Person (k611 C/ (� � Estimated Value of Project: — APPLICANT: DO NOT WRITE BELOW THIS LINE # Submittal Req'd Ree'd TRACKING PERMIT FEES Plan Sets Plan Check submitted Item Amount Structural Calcs. Reviewed, ready for corrections Plan Check Deposit Truss Cal cs. Called Contact Person Plan Check Balance Title 24 Cales. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan 2"a Review, ready for corrections/issue. = Electrical Subcontactor List Called Contact Person Plumbing Grant Deed Plans picked up S.M.I. H.O.A. Approval Plans resubmitted Grading 1N HOUSE:- 3" Review, ready for corrections/issue Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub. Wks. Appr Date of permit issue School Fees, Total Permit Fees I - I I f7 I - �-L-L-L-j -17 1 ill 4 r 1 ! P.O. Box 1504 LA QUINTA, CALIFORNIA 92247-1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT PROPERTY OWNER'S PACKAGE (760)777-7012 FAX (760) 777-7011 Disclosures & Forms for Owner -Builders Applying for Construction Permits IMPO.RTANTI NOTICE TO PROPERTY OWNER Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at '51 F We are providing you with an Owner -Builder Acknowledgment and lnformahon Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION DIRECTIONS: Read and initial each statement below to signer you understand or verify this information. . I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder" ding permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as a Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. I understand building permits are not required to be signed by property owners unless they are responsible for the ction and are not hiring a licensed Contractor to assume this responsibility. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on p is and contracts. . I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" udder state and federal law. ' 6. I understand if I am considered an "employer" under state and federal law, I must register with the state and federal go ent, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment con ensatian for each "employee." 1 also understand my failure to abide by these laws may subject me to serious financial risk. . I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential swes cannot legally build them with the intent to offer them for sale, unless all work is performed by Iicensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. 8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. 9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1- 800-321-CSLB (2752) or www.cslb_ca.gov for more information about licensed contractors. 10.1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally, and financially responsible for proposed construction activity at the following address: 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as.well as employers. 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the agency is required to be presented when the permit is issued to verify the properly owner's signature. Signature of property owner Date: Note: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder. AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: Tel No I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note:.4 copy of the owner's driver's license, form notarization, or other- verification acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: Margarita Mrazek Coss 51662 Eisenhower La Quinta, California 92253 June 30 2016 To whim it may concern City of La Quinta Miguel Rangel will act as my responsible party to the finishing of the construction of my house, he can make any decisions regarding changes and improvements to my property. Sincerely Margarita Mrazek Coss