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13-1482 (BLCK)4 P.O. BOX 1504 VOICE (760) 777-7012 78-495 CALLE TAMPICO FAX (760) 777-7011 LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153 BUILDING PERMIT Date: 11/25/13 Application Number: 13-00001482 Owner: Property Address: 52955 AVENIDA CARRANZA JOSETTE A. WOLLI APN: 773-321-010-10 -000000- 52955 AVENIDAFo1v Application description, WALL/FENCE LA QUINTA, CA 9Property Zoning: COVE RESIDENTIAL ( Application valuation: 300 2,9 2093 Applicant: Architect or Engineer: s a ----------:'---------------------------------------- I 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 Professionals 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 Lice Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or a or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by a plicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars 1$5001.: I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 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 he or she did not build or improve for the purpose of sale.). 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 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 contracts for the projects with a contractor(s) licensed pursuant to the Contractors' State License Law.). late: I am exempt under Sec. , B.&P.C. for this reason N-�L — 12 Owner: V CONSTRUCTION LENDING 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 it issued (Sec. 3097, Civ. C.). Lender's Name: Lender's Address: LQPERMIT Contractor: Owner- -7--------------------------------------------- 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. Date: 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 Director of Building and Safety 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. I certify that I have read this application and state that the above information is c ec .I agree to comply with all city and county ordinances and state laws relating to building construction, and ereb authorize representatives of this county to enter upon the e -mentioned propert for inspection purpo es. Oe: "pwje (Applicant or Agent): l - Application Number . . . . . 13-00001482 Permit . . . WALL/FENCE PERMIT 2013 Additional desc . Permit Fee 61.49 Plan Check Fee .00 Issue Date . . . . 11/21/13 Valuation 300 Expiration Date 5/20/14 Qty Unit Charge Per Extension 1.00 47.1900 LS MISC WALL, FIRST 100 LF 47.19 1.00 114.3000 EA MISC WALL, ADDL 50 LF 14.30 ---------------------------------------------------------------------------- Special Notes and Comments 129LF OF SFT. AND 6FT. HIGH WALL (4) PORTIONS AT FRONT YARD, DRIVE WAY SOUTH PL AND ALONG BACK YARD PL (PER APPROVED ATTACHED PLAN) [ANGELUS SPECIFICATIONS] PRECISION CONCRETE BLOCK SHALL BE COVERED WITH STUCCO, PAINT, OR TEXTURED COATING WHERE VISIBLE FROM OUTSIDE THE PROPERTY. 2010 CALIFORNIA BUILDING CODES. ---------------------------------------------------------------------------- Other Fees . . . . . . . . . BLDG STDS ADMIN (SB1473) 1.00 PLAN CHECK, WALLS 60.06 Fee summary Charged Paid Credited ------------------------------ Due ---------------------------- Permit Fee Total 61.49 47.19 .00 14.30 Plan Check Total .00 .00 .00 .00 Other Fee Total 61.06 61.06 .00 .00 Grand Total 122.55 108.25 .00 14.30 LQPERMIT P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: 13-00001482 Property Address: 52955 AVENIDA CARRANZA APN: 773-321-010-10 -000000- Application description: WALL/FENCE Property Zoning: COVE RESIDENTIAL Application valuation: 300 T414t 4 4 4" BUILDING & SAFETY DEPARTMENT BUILDING PERMIT Owner: JOSETTE A. WOLLASTON 52955 AVENIDA CARRANZA LA QUINTA, CA 92253 ( Contractor: Applicant: Architect or Engineer: Owner �w 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 Professionals 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 Lice n a Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that or she's exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by a licant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).: I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 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 he or she did not build or improve for the purpose of sale.). 1 I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 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 contrac r the projects with a contractor(s) licensed pursuant to the Contractors' State License Law.). 1 I am exempt ?under Sec. &P.C. for this reason Date: I -azl Owner: CONSTRUCTION LE DING AGENCY I hereby affirm under penalty of perjury th here 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 Address: ::A4 LQPERMIT VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 11/21/13 D Nov 12013 4 City QF l a ®Ui'WA FINANCE DEPT. 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 r 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 sj t to the workers' compensation laws of California, and agree that, if I should become subje t t the the compensation provisions of Section 3700 of the Labor Code, I shall forthwi h c mply with those provisions. Date: 1-011- 6 Applicant: &Qz" U ",64 - WARNING: FAILURE TO SECUO 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 Director of Building and Safety 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. I certify that I have read this application and state that the above information is co ct. I agree to comply with all city and county ordinances and state laws relating to building construction, and ere y authorize representatives of this county to enter upon the above-mentioned property for inspection purp es. Date' `ot1' 3 Signature (Applicant or Agent): 3 Application Number . . . . . 13-00001482 Permit . . . WALL/FENCE PERMIT 2013 Additional desc . Permit Fee . . . . 47.19 Plan Check Fee .00 Issue Date . . . . Valuation 300 Expiration Date 5/20/14 Qty Unit Charge Per Extension 1.00 47.1900 LS MISC WALL, FIRST 100 LF 47.19 -----------------------------=---------------------------------------------- Special Notes and Comments 79LF OF 5 AND 6 WALL (3) PORTIONS AT \ FRONT YARD, DRIVE WAY AND SOUTH PL [ANGELUS SPECIFICATIONS] PRECISION CONCRETE BLOCK SHALL BE COVERED WITH STUCCO, PAINT, OR TEXTURED COATING WHERE VISIBLE FROM OUTSIDE THE PROPERTY. 2010 CALIFORNIA BUILDING CODES. ---------------------------------------------------------------------------- Other Fees . . . . . . . . BLDG STDS ADMIN (SB1473) 1.00 PLAN CHECK, WALLS 60.06 Fee summary Charged Paid Credited --------------------------------------------------------- Due Permit Fee Total 47.19 .00 .00 47.19 Plan Check Total .00 ..00 .00 .00 Other Fee Total 61.06 .00 .00 61.06 Grand Total 108.25 .00 .00 108.25 LQPERMIT Dir' n City of La Quinta Building 8i Safety Division Permit # P.O. Box 1504, 78-495 Calle Tampico La Quinta, CA 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet Project Address: P Owner's Name: ALf,,An 1_-Se4k. IKA i La to 40n A. P. Number: Address: Legal Description: City, ST, Zip: Contractor: Telephone: _ FEW ;:;•;::;:!.:;.,.:::;:•;.. Address: Project Description: City, ST, Zip: Item Telephone: <>z :.?s 5 f `>.. , , is N-, Structural Calcs. State Lic. # : City Lic. #: C'd "1' A I I Arch., Engr., Designer. Plan Check Deposit Address: I Z City., ST, Zip: Telephone: .,...,,.,:.,�.;Construction •: : Type: Occupancy: f . Project type (circle one): New Addn Alter Repair Demo ' State Lic. # . �!'i':Y i�• S�hiy�?' v:?S:�%iJ}.�ii�ilti:iiii 'y.` r•<:%.ryivii::iie<ji ii •"fry-2!�+tiiv%i::iii. �i.��`: ::;!.<.:<•;:.;:::•>:;;:.:!•;: <.�.?<':;!>A;�•;<�:;::::;;;;;;:�<»;�;-;:;.:v;.< ........:.. :.....................:..:............:: Name of Contact Person:Sq. Ft.: # Stories: # Units: Telephone #,of Contact Person -,t Estimated Value of Project: IDO Ir APPLICANT: DO NOT WRITE BELOW THIS LINE 1 # Submittal Req'd Recd TRACKING PERMIT FEES Plan Sets Plan Check submitted Item Amount Structural Calcs. Reviewed, ready for corrections Plan Check Deposit Truss Cala. Called Contact Person Plan Check Balance Title 24 Calcs. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan 2°" 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 IN HOUSE:- '"' 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 ,. r ITY OF LA UILDING & SAFE1YIDEPT. FOPPRO /E® R%CONSTRUCTION E Il/. ,.11 = CITY OF LA QUINTA BULDING' & SAFETY DEPT. APPROVED DATd 21` 13 BY - V' ! r ' 13 /o c na 2F-5 e _ 52 5' NUENMO/\ C-pseWat,lZ/� Ola QUIY►7-A CA 9Z 53 6Y �6 C) 0� F' .,a-' 7, i i i w awCK Ca, INC. Since 1949 ANGELUS BLOCK MASONRY FENCE WALL SYSTEM DESIGN CRITERIA: 1. DESIGN CRITERIA PER 2010 CBC 2. ALLOWABLE SOIL BEARING PRESSURE = 1500psf 3. ALLOWABLE SOIL PASSIVE PRESSURE = 150pcf 4. COEFFICIENT OF FRICTION a 0.25, COHESION - Opsf 5. CANTILEVER ACTIVE = 30pcf 6. MASONRY COMPRESSIVE STRENGTH, fm - 1500ps1. SPECIAL INSPECTION NOT REQUIRED PER CBC SECTION 1704.1 EXCEPTION 3, 'U' OCCUPANCY. 7. USER TO VERIFY APPLICABILITY OF THE DEFINED DESIGN CRITERIA FOR THE PROJECT SPECIFIC SITE. NOTES: 1. REINFORCING STEEL SHALL BE DEFORMED AND CONFORM TO ASTM A615 GRADE 60. PROVIDE SPLICES (LAPS) OF 48 BAR DIAMETERS OR 24 INCHES, WHICHEVER IS GREATER. CENTER VERTICAL BARS IN CELLS. 2. JOINT REINFORCEMENT ("LADDER" TYPE) SHALL BE COLD -DRAWN STEEL WIRE CONFORMING TO ASTM A951. PROVIDE MINIMUM 6 INCH LAP SPLICES. 6' to 8' High Site Wall Spread Footing o Property Line C o 85mph 6w Wide CMU OPTIONAL WALL COURSE, AND 24'o.c. 5. MORTAR SHALL BE SPEC MIX TYPE S PREBLENDED MASONRY MORTAR AS MANUFACTURED BY E -Z MIX INC., CONFORMING TO PROPORTIONS AND REQUIREMENTS OF ASTM C270, OR SPEC MIX IWR MASONRY MORTAR AS MANUFACTURED BY E -Z MIX INC., CONFORMING TO PROPERTY REQUIREMENTS OF ASTM C270. 6. GROUT SHALL CONFORM TO ASTM C476, WITH AN B-11 INCH SLUMP, AND SHALL HAVE A MINIMUM COMPRESSIVE STRENGTH AT 28 DAYS OF 2000ps1. 7. FIRST COURSE MAY BE WET -SET 1 1/2 INCHES MAX, WHILE CONCRETE IS PLASTIC. 8. CONCRETE BLOCK SHALL BE LAID IN RUNNING BOND PATTERN WITH VERTICAL CONTINUITY OF THE CELLS. 9. VERTICAL CONTROL JOINTS SHALL BE SPACED AT A MAXIMUM OF 40'-0"o.c. OR 20'-0"o.c. IF WALL IS TO BE STUCCO COATED OR MORTAR WASHED 10: GROUT ALL CELLS WITH REINFORCEMENT. 11. INSPECTIONS: A. AFTER FOOTING IS READY FOR CONCRETE AND ALL FOOTING REINFORCING IS TIED IN PLACE. B. AFTER VERTICAL REINFORCEMENT IS IN PLACE AND CELLS ARE READY FOR GROUT. f2. FOR TYPICAL FOOTING STEP AND DRAINAGE BLOCK-OUT DETAILS SEE DETAIL SHEET S-5.1. 'X' BARS PER SCHEDULE 0 CTR. OF WALL I 'Y' BARS PER SCHEDULE LAP PER 'L' WET -SET FIRST COURSE 2-d4 CONT CONT. CONC. 6' WIDE (NOM.) CMU 3. STRENGTH OF CONCRETE FOR FOOTINGS = 2500ps1 0 28 DAYS, UNLESS GROUT CELLS' ' OTHERWISE REQUIRED BY SOILS REPORT. w/ REINF. 4. CONCRETE MASONRY UNITS SHALL CONFORM TO ASTM C90. ANGELUS 'L' STEM BLOCK PRECISION, SPLIT FACE, BURNISHED, OR SHOTBLAST, WITH OR WITHOUT MORTARLESS. HEAD JOINTS (TONGUE -AND -GROOVE), OR I8' LONG CMU TYPE PER S-2.0 16" ANGELUS BLOCK SLUMPSTONE SHALL BE USED. 18' CMU 5. MORTAR SHALL BE SPEC MIX TYPE S PREBLENDED MASONRY MORTAR AS MANUFACTURED BY E -Z MIX INC., CONFORMING TO PROPORTIONS AND REQUIREMENTS OF ASTM C270, OR SPEC MIX IWR MASONRY MORTAR AS MANUFACTURED BY E -Z MIX INC., CONFORMING TO PROPERTY REQUIREMENTS OF ASTM C270. 6. GROUT SHALL CONFORM TO ASTM C476, WITH AN B-11 INCH SLUMP, AND SHALL HAVE A MINIMUM COMPRESSIVE STRENGTH AT 28 DAYS OF 2000ps1. 7. FIRST COURSE MAY BE WET -SET 1 1/2 INCHES MAX, WHILE CONCRETE IS PLASTIC. 8. CONCRETE BLOCK SHALL BE LAID IN RUNNING BOND PATTERN WITH VERTICAL CONTINUITY OF THE CELLS. 9. VERTICAL CONTROL JOINTS SHALL BE SPACED AT A MAXIMUM OF 40'-0"o.c. OR 20'-0"o.c. IF WALL IS TO BE STUCCO COATED OR MORTAR WASHED 10: GROUT ALL CELLS WITH REINFORCEMENT. 11. INSPECTIONS: A. AFTER FOOTING IS READY FOR CONCRETE AND ALL FOOTING REINFORCING IS TIED IN PLACE. B. AFTER VERTICAL REINFORCEMENT IS IN PLACE AND CELLS ARE READY FOR GROUT. f2. FOR TYPICAL FOOTING STEP AND DRAINAGE BLOCK-OUT DETAILS SEE DETAIL SHEET S-5.1. 'X' BARS PER SCHEDULE 0 CTR. OF WALL I 'Y' BARS PER SCHEDULE LAP PER 'L' WET -SET FIRST COURSE 2-d4 CONT CONT. CONC. ANDERSON DESIGN GROUP Structural Engineering • Building Design 228 East Badillo Street • Covina • CA • 91723-2115 (626) 938-1595 • Facsimile (626) 938.0485 ..--g,neanng excB11.n .Inca 1957. 'W MIN. PER SCHEDULE Cr 9 'fV 3' CLR. TYP. 4 111mi 'MASONRY FENCE WALL SCHEDULE 'H' MAX. -X "BARS REINF.WA L STEM 'BARS -LONG 'L' STEM 'W MIN. 16' LONG CMU I8' LONG CMU TYPE PER S-2.0 16" LONG CMU 18' CMU 6'-0" 4048'o.c. A4.o.c. (j4054'o.c. 4®27 o.c. 2-0' 3::-5 :'B' 4048"o.c, 4064°6.c. 2'-O" 2-2" 6'=8' #4048'o.c. #4045'0.c. A' 4016'o.c• 4018"o.c. 2•'-0" 3'-10"' B 048"o.c.4045'o.c. 2'-0' 2'-4" T-4" �14048'o.c. #4045'o.c. A' 4016"o.c: 4018"o.e: 3=0 '4=1 " , B. 048'o.c. 4C45'6.c: 2'-0' 2-7" I 8'-0" �4040b.c.4036b.c. A' 'B' 40B"o.c. 409"o.c. 3'-4'' 4'-4", iS 4040"o.c. 4036"O.c. 2'-0' ANDERSON DESIGN GROUP Structural Engineering • Building Design 228 East Badillo Street • Covina • CA • 91723-2115 (626) 938-1595 • Facsimile (626) 938.0485 ..--g,neanng excB11.n .Inca 1957. 'W MIN. PER SCHEDULE Cr 9 'fV 3' CLR. TYP. 4 111mi 8' High Max. Site Wall C o 86mph SLOCKC0.1MC. 60 Wide CMU Since 1948 ANGELUS BLOCK MASONRY FENCE WALL SYSTEM ,END; OF WALL A 5 X H, o 0 :o X X uw 1%A4 o: oo oX RETURN rf`P: 5 x HF 'I 0 5 :HFt TYPICAL REINFORCED WALL STEM TYPES PLAN O. WALL TYPES & TOTAL WALL LENGTH 5 X HF MIN. 5 x HF MIN. TYPICAL REINFORCED WALL STEM TYPES ELEVATION t. WALL TYPES & 00 . N ANDERSON DESIGN GROUP Al""wStructural Engineering . Building Design 228 East Sadillo Street • Covina * CA e 91723-2115 (626) 938-1595Facsimile (626) 938-0485 -_a'­_g• B 11__ V- 1957, P.O. Box 1504 LA QUINTA, CALIFORNIA 92247-1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 e BUILDING &`SAFETY DEPARTMENT PROPERTY OWNER'S PACKAGE (760) 777-7012 FAX (760) 777-7011 Disclosures & Forms for Owner -Builders Applying for Construction Permits OTAIYTt NOTUCE TO 1PROPERTY OWNER Dear Property Owner. An. application for a building permit has been.: submitted in your name listing yourself as the builder of the .property impt ovements specified at 52- 9 S S We are providing you with an Owner -Builder Acknowledgment -and Information•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 wilt not issue -a building permit until you have read, initiated your: nuderstandiag 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. D1`RECUIONS. Read and initial each statement below to signify you understand or verify tk s;brmation. 1. I understand• a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder' sir ing permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an 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 - 2. I understand building permits are not required to be signed by property owners unless they are responsible for the nstruction and are not hiring a licensed Contractor to assume this responsibility: 3. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect If from potential financial risk by hiring a licensed Contractor and having the permit flied in his or her name instead of my wn. 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on rmits and contracts. 5.1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value o my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. U6. I understand if I am considered an "employer" under state and federal law, I must register with the state and federal tverament, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment ovmpensatio'n for each "employee." I also understand my failure to abide by these laws may subject me to -serious financial not, 7. I understand under California Contractors' StateLicense Law, an Owner -Builder who builds single-family residential ures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed bcontractors 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. it8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable. for any nm cial or personal. injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. g9. I understand I may obtain more information regarding my obligations as an "employer" from the Interffi1 Revenue e 'cc, the United States Small Business Administration, the California Department of Benefit Payments, and the California ivision of Industrial Accidents. I also understand 1 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. am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the fady 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 cable laws and requirements that govern Owner -Builders as well as employers. 12.1 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,. fire Contractors' State License Board may be unable to assist4you. with any finanew I= you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be iwcivil court. It is also important for you to: understand that if an unlicensod Contractor or employee of that individual or fora 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 tkir workers' coition 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. ismiing,Ow. .permit Note: A copy of tkc property owner's driver'sikertsej form nate a; or other verification acceptable to the agency is require be 'presented when the permit is. issued to verify the pr+vperty owner's signature. Signature of property owner n fDate: 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: Tel No Address of Authorized Agent: 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:'A 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: