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BRES2016-029778-495.CALLE TAM PICO LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT Date: 10/13/2016 BUILDING PERMIT Application Number: BRES2016-0297 Property Address: 79405 CALLE PROSPERO APN: 604382019 Application Description: WOOD/ REMODEL BATHROOM Property Zoning: Application Valuation: $18,300.00 Applicant: CRAIG AND NANCY WOOD 79405 CALLE PROSPERO LA QUINTA, CA 92253 LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my License is in full force and effect. License Class: License No.: Date: Contractor: OWNER -BUILDER DECLARATION I I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($ 00).- 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 Nor he did not build or improve for the purpose of sale.). 0 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 Co tractors' State License Law.). Y( `MOiI` am exempt under Sec. . B.&P.C. for this reason Date: I0—' �! Owner: . CONSTRUCTICIENDING 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 Address: VOICE (760) 777-7125 . FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Llc. No.: 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: C i 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' C PENSA N 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 ssued 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 application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upo the above-mentioned property for inspection pur ses. Date: �a—'_3 Signature (Applicant or Age Date: 10/13/2016 Owner: - CRAIG AND NANCY WOOD 79405 CALLE PROSPERO LA QUINTA, CA 92253Lo t Contractor. OWNER BUILDER �p U I O 1 Llc. No.: 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: C i 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' C PENSA N 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 ssued 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 application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upo the above-mentioned property for inspection pur ses. Date: �a—'_3 Signature (Applicant or Age Date: 10/13/2016 Application Number: BRES2016-0297 Owner: Property Address: 79405 CALLE PROSPERO CRAIG AND NANCY WOOD APN: 604382019 79405 CALLE PROSPERO Application Description: WOOD / REMODEL BATHROOM LA QUINTA, CA 92253 Property Zoning: Application Valuation: $18,300.00 Applicant: Contractor: CRAIG AND NANCY WOOD OWNER BUILDER 79405 CALLE PROSPERO LA QUINTA, CA 92253 Llc. No.: Detail: BATHROOM REMODEL - RELOCATE. TOILET, INSTALL 36" POCKET DOOR, ROLL IN SHOWER, RESESSED LED LIGHTING, VANITY, FRAME AND DRYWALL OLD DOORWAY. 2013 CALIFORNIA BUILDING CODES. FINANCIAL INFORMATION DESCRIPTION ACCOUNT QTY AMOUNT BSAS SB1473 FEE 101-0000-20306 0 $1.00 Total Paid for BUILDING STANDARDS ADMINISTRATION BSA:' $1.00 DESCRIPTION ACCOUNT QTY AMOUNT RESIDENTIAL, FIRST 1,000SF 101-0000-42403 0 $152.00 DESCRIPTION ACCOUNT QTY AMOUNT RESIDENTIAL, FIRST 1,000SF, PC 101-0000-42600 0. $50.16 Total Paid for ELECTRICAL - NEW CONSTRUCTION: $202.16 DESCRIPTION ACCOUNT QTY AMOUNT VENT FAN 101-0000-42402 0 $12.67 DESCRIPTION ACCOUNT QTY AMOUNT VENT FAN PC 101-0000-42600 0 $5.07 Total Paid for MECHANICAL: • $17.74 DESCRIPTION ACCOUNT QTY AMOUNT FIXTURE/TRAP. 101-0000-42401 0 $38.01 DESCRIPTION ACCOUNT QTY AMOUNT FIXTURE/TRAP PC 101-0000-42600 0 $38.01 DESCRIPTION ACCOUNT QTY AMOUNT WATER SYSTEM INST/ALT/REP 101-0000-42401 0 $12.67 DESCRIPTION ACCOUNT QTY AMOUNT WATER SYSTEM INST/ALT/REP PC 101-0000-42600 0 $12.67 Total Paid for PLUMBING FEES: $101.36 DESCRIPTION ACCOUNT QTY AMOUNT REMODEL, FIRST 100 SF 101-0000-42400 0 $51.68 DESCRIPTION ACCOUNT QTY AMOUNT REMODEL, FIRST 500 SF PC 101-0000-42600 0 $141.36 Total Paid for REMODEL: $193.04 DESCRIPTION ACCOUNT QTY AMOUNT SMI - RESIDENTIAL 101-0000-20308 0 $2.38 Total Paid for STRONG MOTION INSTRUMENTATION SMI: $2.38 DESCRIPTION ACCOUNT QTY AMOUNT TECHNOLOGY ENHANCEMENT FEE 502-0000-43611 0 $5.00 Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00 c� 5 L �Tf(e (cop Construction is NOT PERINEMENTIAL PLAN CHECK APPLICATION on the following Code holidays: FOR BATHROOM REMOD .. �,TyOFLAQUINTA New Year's Day BULDING & SAFETY DEPT. Dr[YAf, E�uther King Jr. D?October 12, 2016 P i ��/ President's Day FOR C0,1N;ZIUCTION Memorial Day InAPP;IRUCANT: Craig and Nancy Wood f � Labor Day ,�T�--t- Veteran's Day T QyR �ff3' ADDRESS: 79405 Calle Prospero, La Quinta 92253 rise-das Day DESCRIPTION: APN#:604-38-2019-3 .17 Acres in Lot 110, MB 268/047 TR 25953 �� rn N W m o FoRstruction shall comply with the 2013 California C-3 K= m- Resii� EA-Fal�Ej � m z o tical, Electrical, Plumbing, Energy, and Green iQ�e o C Q � �^ nd the La Quinta Municipal Code. o -D ---IC/13 -� = z C ar� a= m m o C) M mc7mEz� z Damm `�lalr&m be the 1/0 or larger, 4^�Cn and o o conductors will size of or sub -panels. All other current carrying condu-tares N t�l�ieopper. (LQMC § 8.03.040) 2, r'n � �no�C-� Will provide at least one 20 -ampere branch circuit to ss_ r=v�m bathroom receptacles. Such circuit(s) shall have no other outlets. (CEC §210.11(C)(3);210.52(D). CONSTRUCTION HOURS Will provide GFCI Protection for receptaclest irbaXhc (CEC §210.8(A)(1). Monday - Friday: 7:00 a.m. to 5:30 p.m. 5uture,ay: 8:00 a.m. to 5:00 p.m. Sunday: None Laver ent Code ol- s• None Luminaires (light fixtures) in tub or shower en,c oos,,ures shad ie Way is � lY1�LY/eraiaer 3ilth labeled suitable for damp location'. (CEC §410,4(M).Friday: 6:00 a.m. to 7:00 p.m. svur} , AV: 8:00 a.m. to 5:00p.m. �� swle; . None Prepared by: Nancy Wo Go`vtranieniCodeHolidays: None Signature: rl (760) 772-9355 o4 A6) 574-7167 Cell Page 1 of 2 Location of all existing and proposed smoke or carbon monoxide alarms will be shown on plan (CRC Chapter 1, §106.1.1). Hot -mop shower pan shall be inspected upon completion of hot - mopping and shall comply with CPC §411.8.1). In the bathroom, permanently installed luminaires that are not high efficiency will be controlled by a manual -on occupant sensor(s). (California Energy Code §150(k) 3). The plan contains the following table of requirements: FIXTURE FLOW RATES FIXTURE TYPE MAXIMUM FLOW RATE Showerheads 2 gpm @ 80 psi Lavatory faucets 1.5 gpm @ 60 psi Kitchen faucets 1.8 gpm @ 60 psi Water closets 1.28 gallons/flush Urinals 0.5 gallon/flush `ITYOF LA QUINTA B4_ ;I Q!NG & SAFETY DEPT. i"PR 0 V E FOR CONSTRUCTION MATE By Prepare Nanc o Signature: (760) 772-9355 Hoe (760) 574-7167 Cell Page 2 of 2 ,T Iain It City of La Qu'nta J Building 8t Safety Division Pe,mi[ 4 : 78-495 Calle Tampico La Quinta, CA 92253 (760) 777-701,2 Building Permit Applicatidn and Tracking Sheet Projcc� tAddress:�•� ��•/� (�� 1 q � �'� �' Owner shame:= A. P. Number: 3 _ �3 Address: Legal Description: l_bfi io µB 2- o city E --z ip: 7eiv Contractor: Tefephonc• L� Address: Project Descriptio : City, ST, Zip: -Dgmo - d'1DWP.v�AA Telephone: hone: MEMMM ch State Lic. # : City Lic.- a✓ g Arch., Engr., Designer: - Address: s V City, ST, Zip: dRes(S6lS Qi Telephone: Construction T e: Occupancy: yP r StateLic. # - • Pr(circle one): Nev Add'n Alter Repairair oJeet type Demo 0 Name of Contact Person: -" Sq. Ft-: #Stories: #Units: 'Telcphone.tl ofCon=LPcrso. I Estimated Value of Project: ) APPLICANT: DO NOT WRITE BELOW THIS LINE t< Submittal Req'd , Rcc'd TRACKING . PERMIT FEES Plan Sets Plan Check submitted Item Amount Structural Cafes. Reviewed, ready for corrections Plan Check Deposit Truss Calcs. 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 : _ co ac List Called Contaef Person _ , Plumbing Grant Deed Plans picked up o S.M.I. I-I.O.A. Approval [� Plans resubmitted " Grading' IN HOUSE:- 'r° Rcyicw, 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 f- 78-495 CALLS TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT (760) 777-7012 FAX (760) 777-7011 Considering Becoming an Owner -Builder? Important information you need to know BEFORE pulling your permit! The term "Owner -Builder" can mean three different things: "Owner as Worker", "Owner as Contractor" or ".Owner as Employer" Understand each has Benefits or Risk, and it is possible to combine them! Hiring a California Licensed Contractor means you do not personally perform any of the construction work, the permit is not taken out in your name, you are not personally responsible for the construction and you are not an Owner -Builder. Instead, you become a "Customer" and California law provides you the benefit of protection from poor workmanship, .failure to finish the job and financial risk due to worker injury. Bene it/Risk: Highest Benefits and.the Least amount of Risk Owner -as -Worker is a type of Owner -Builder where you personally perform the construction, work, the permit is taken out in your name and you are personally responsible for the construction management, knowledge, workmanship,'and completion of the job. You benefit by not paying others to perform this work for you and your risk depends on your own ability to complete the job successfully. Benefit/Risk: Possible Benefit with Lova Financial Risk Owner -as -Contractor is a type of Owner_Builder where you personally act as your own General Contractor, the permit is taken out in your name and you hire California licensed sub -contractors to perform portions of the construction'work. WARNING: The benefit of protection provided by law when you hire only California licensed sub -contractors can turn to serious financial risk if you hire unlicensed contractors to perform any of the work. Benefit/Risk: Possible Benefit and Significant Financial Risk Owner -as -Employer is a type of.Owner-'Builder where you pay any unlicensed individual to perform any construction work valued at more than $500.00, the permit is taken .out in your name and you are. personally responsible for their employment requirements, supervision, performance, safety and welfare while on your property. WARNING: Cost savings benefit can turn'to serious financial -risk if you fail to deduct payroll taxes or provide workers compensation insurance for each worker. Benefit/Risk: Possible Benefit with Significant Financial Risk (Health and Safety Code Section 19827) The California Legislature declares an "urgent and statewide public interest in assuring" that contractors comply with Contractors' License Law, Business and Professions Code and Workers' Compensation Insurance requirements to ensure property owners are informed about, and protected from the following when improving their property as Owner -Builders: Fraudulent representations - Liability for worker's injuries • Liability for material and labor costs unpaid by contractors • Licensing requirements - Employers tax liabilities Over 20,000 consumer complaints are filed each year. Many complaints relate to owner/builder projects and include workmanship and workers' compensation issues Homeowners suffer financial harm due to defective workmanship and injured employees. Following are alarming examples of what has occurred with Owner -Builder permits: Example 1: Homeowner received insurance money to rebuild burned -down home. ■ Owner/Builder permit pulled to rebuild structure. ■ . Unlicensed contractor built substandard structure — must be torn down and replaced. ■ Estimated financial injury is $225,000. ■ Additional financial injury - IRS threatened to tax insurance payout if house not completed by the end of the year. Example 2: Brother-in-law had active license but fled an exemption from Workers Comp. ■ Owner -Builder hires brother-in-law to install a new roof. ■ Employee falls and sustains multiple spinal and extremity fractures as well as ahead injury and remains in a coma to this day. ■ The Owner -Builder, who has sold the home, is now a defendant in a lawsuit for reimbursement for benefits paid to the injured worker. Example 3: Employee of contractor without Workers Comp is hired by Owner -Builder to install septic system and suffers injury that results in permanent disability. ■ The Owner -Builder did not have a homeowner's insurance policy on the house against which to submit a claim. • The -Owner -Builder is now a defendant in a lawsuit for reimbursement for benefits paid to the injured worker. Did you know — unlicensed persons frequently have the property.owner obtain an "Owner -Builder" building permit which erroneously implies that the property owner is providing his or her own labor and material personally? Did you know — your homeowner's insurance may not provide coverage for injuries sustained on your property by an unlicensed contractor and his/her employees? Did you know — if you are considered an "employer" under state and federal law, you must register with the state and federal government, withhold payroll taxes, provide workers compensation and disability insurance and contribute to unemployment compensation for each "employee"? Did you know — that if you fail to abide by these laws you may be subjected to serious financial risk? . OWNERS BEWARE AND CONSIDER THE RISK BEFORE ACCEPTING FULL RESPONSIBILITY FOR YOUR CONSTRUCTION PERMIT P.D. Box 1504 LA QUINTA, CALIFORNIA 92247-1504 78-495 CALLS 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 IMPORTANT! NOTICE TO PROPERTY OWNER Dear Property Owner: •An . application for a building permit s been submitted in your name listing yourself as the builder of the property improvements specified at Q&rwe a e.13 We are providing you with an Owner -Builder Acknowl ent 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 will notissue 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 youi 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" building 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 roperty. I understand buildingpermits are not required t P q o be signed by property owners unless they are responsible' fol the cons ction and are not hiring a licensed Contractor to assume this responsibility. `/3I understand as an"Owner- " Builder I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. 4. I understand Contractors are required by law to be licensed and bonded. in California and to list their license numbers on permi 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 under to and federal law. considered an ".employer" 6. I understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to.serious financial risk understand under California Contractors' Statei - L cense Law, an Owner Builder who builds single-family residential structures cannot legally build. them with the intent to offer them for sale, unless all work is performed by licensed 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 workm nship or materials. 9. I understand I may obtain more information regarding my obligations as an."employer" from the Internal Revenue ervice, 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. 1`-1vi 0. 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 financiallyresponsible for proposed construction activity at the following address: r7,7. -6 n _ Q VYW 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicab>e laws and requirement$ that govern Owner -Builders as.well as employers. _""YW2. 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 property owner's signature. Signature of property owner Date: I� 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 owners signature. Property Owner's Signature: Date: a 4905 Belfort Road, Suite 110 Jacksonville, FL 32256 POLICY NUMBER � NP3030716 STILLWATER For Service call 1-800-691-3817 HOMEOWNERS 3 SPECIAL FORM INSURANCE COMPANY For Claims call 1-877-679-9835 Client ID 000005994871 SUMMARY OF THIS POLICY EXPIRES ON 10/11/2016 RENEWAL OFFER RENEWAL COVERAGES OFFERED YOUR POLICY WILL LAPSE IF PAYMENT IS NOT MADE BY 10/10/2016 INSURED AGENT CRAIG WOOD GEICO INSURANCE AGENCY INC NANCY WOOD PO BOX 9503 79405 CALLE PROSPERO FREDERICKSBURG VA 22403-9503 LA QUINTA CA 92253-8561 (800) 691-3817 EFFECTIVE 10/11/2016 TO 10/11/2017 LOCATION OF RESIDENCE PREMISES 79405 CALLE PROSPERO LA QUINTA CA 92253-8561 EFFECTIVE TIME IS 12:01 A.M. STANDARD TIME AT YOUR RESIDENCE SECTION I PROPERTY COVERAGES COVERAGE A COVERAGE B COVERAGE C COVERAGE D DEDUCTIBLE DWELLING OTHER STRUCTURES PERSONAL PROPERTY LOSS OF USE $ 3000 $ 494,400 $ 49,440 $ 346,080 $197,760 SECTION II LIABILITY COVERAGES COVERAGE E - PERSONAL LIABILITY $ 300,000 EACH OCCURRENCE COVERAGE F - MED PAY TO OTHERS $ 2,000 EACH PERSON OVERAGE A - DWELLING ,_ _ LIMIT PREMIUMICREDIT ._,.-. «.- - �- $494,400 - --- -- -$-1-260.00- OVERAGE B - OTHER STRUCTURES $49,440 OVERAGE C - PERSONAL PROPERTY $346,080 OVERAGE D - LOSS OF USE $197,760 OV E - PERSONAL LIABILITY n $300,000 $20.00 OV F - MED PAY TO OTHERS, „ // $2,000 $3.00 :OME ALERT PROTECTION ��/ i a Iq " 00 $341.00- EPLACEMENT COST - CONTENTS 1 . :OMEOWNERS INFLATION GUARD 3% -ISCOUNTS: .GE OF INS (50-59) DSC, PERSONAL STAT DSC, TILE ROOF DSC, UTILITIES RATING PLAN 09% OSS EXPERIENCE ADJ... $ 96.73 - TOTAL POLICY PREMIUM $ 1019.00 NO COVERAGE IS PROVIDED UNDER THIS POLICY FOR LOSS CAUSED BY EARTHQUAKE MORTGAGEE(S): LOAN # PENNYMAC LOAN SERVICING, LLC 8000018405 If you have any questions regarding this offer, please contact your agent. If you are unable to resolve the issue with your a en_t' you may contact us at 1-800-691-3817. SEE REVERSE SIDE FOR POLICY FO0 t ENDORSEMENTS FAMILIES/ YEAR OF P/G FT MILES FIRE APARTMENTS CONSTR CONSTR O/G TERR HYDRANT F. DEPT DISTRICT 001 20011. FRAME 04 * * 803 999 4 I1515H (08-03) INSURED CA 08/22/2016 H9X 002 IDA0907 COPY 1 OF 2 140600000000003071616236 00003 JAY