BWFE2016-0173LICENSED 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
permit subjects the applicant to a civil penalty of not more than five hundred dollars
( 500).:
<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
or she did not build or improve for the purpose of sale.).
,ft`R 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.).
A?1 am exempt under Sec. . B.&P.C. for this reason
Date: Z—O.wnerC
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 is issued (Sec. 3097, Civ. C.).
Lender's
Lender's Address:
Ir
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 polity 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 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.
I 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 e r upon the
above-mentioned pr%perty for inspection purposes.
Dates,Lo�.Signatiare (Applicant or g n0
CALLE TAMPICO
D � �
VOICE (760) 777-7125
.78-495
LA QUINTA, CALIFORNIA 92253
,
FAX (760) 777-7011
j
DESIGN & DEVELOPMENT DEPARTMENT
INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: 7/29/2016
Application Number:
BWFE2016-0173
Owner:'"
Property Address:
45680 COLDBROOK LN LN
ANTHONY WIANT
APN:
604424011
Application Description:
ANTHONY WIANT / BLOCK WALL
92253
Property Zoning:
Application. Valuation:
$4,500.00
i D
Applicant:
Contractor: JUL 29 2016
ANTHONY WIANT
OWNER BUI DE
OF IA QUINTA
CITY
COMMIryITY DEVv L�"i1 DEPARTMEN
+
`
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
permit subjects the applicant to a civil penalty of not more than five hundred dollars
( 500).:
<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
or she did not build or improve for the purpose of sale.).
,ft`R 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.).
A?1 am exempt under Sec. . B.&P.C. for this reason
Date: Z—O.wnerC
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 is issued (Sec. 3097, Civ. C.).
Lender's
Lender's Address:
Ir
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 polity 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 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.
I 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 e r upon the
above-mentioned pr%perty for inspection purposes.
Dates,Lo�.Signatiare (Applicant or g n0
Date: 7/29/2016
Application Number: tr BWFE2016-0173 Owner:
Property Address: 45680 COLDBROOK LN LN ANTHONY WIANT
APN: 604424011
Application Description: ANTHONY WIANT/ BLOCK WALL 92253
Property Zoning:
Application Valuation: $4,500.00
9
Applicant: Contractor:
ANTHONY WIANT OWNER BUILDER
92253
Llc. No.:
----------------------------------------------'-----------------------------------------------
"'D2Ydif `S LF OF 6" 6ARDEN WALL FRONT OF THE HOUSE [CITY SPECIFICATIONS] PRECISION tOkN ?TE BLOCK SHALL BE COVERED WITH STUCCO, PAINT, OR
TEXTURED COATING WHERE VISIBLE FROM OUTSIDE THE PROPERTY. 2013 CALIFORNIA BUILDING CODES.
DESCRIPTION
FINANCIAL INFORMATION
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
WALL/FENCE - FIRST 100 LF
101-0000-42404
0
$47.86
DESCRIPTION ,
ACCOUNT
QTY
AMOUNT
WALL/FENCE - FIRST 100 LF PC
101-0000-42600
0
$60.91
Total Paid for FENCE OR FREESTANDING WALL: $108.77
Permit Details PERMIT NUMBER
City of La Quinta BWFE-2011V017 3
Description: ANTHONY WIANT/ BLOCK WALL
Type: WALL/FENCE Subtype: CITY STANDARD/PRE- Status: APPROVED
Applied: 7/29/2016 RSE
APPROVED
Approved: 7/29/2016 RSE
Parcel No: 604424011 Site Address: 45680 COLDBROOK LN LN LA QUINTA,CA 92253
Subdivision: TR 23995-8 Block: Lot: 50
Issued:
Lot Sq Ft: 0 Building Sq Ft: 0 Zoning:
Finaled:
Valuation: $4,500.00 Occupancy Type: Construction Type:
Expired:
No. Buildings: 0 No. Stories: 0 No. Unites: 0
Details: 92LF OF 6' GARDEN WALL FRONT OF THE HOUSE [CITY SPECIFICATIONS] PRECISION CONCRETE BLOCK SHALL BE COVERED WITH
STUCCO, PAINT, OR TEXTURED COATING WHERE VISIBLE FROM OUTSIDE THE PROPERTY. 2013 CALIFORNIA BUILDING CODES.
ADDITIONAL
CHRONOLOGY
• •
NAME TYPE NAME
CONTACTS
ADDRE5S1 CITY — STATE ZIP PHONE FAX EMAIL
APPLICANT ANTHONY WIANT.
92253
CONTRACTOR OWNER BUILDER
OWNER ANTHONY WIANT
92253
,: DESCRIPTION ACCOUNT ..... ... ,.,.,... _ ,..
QTY AMOUNT PAID PAID DATE RECEIPT # CHECK # METHOD PAID BY CLTDBY
BSAS SB1473 FEE 101-0000-20306 0 $1.00 $1.00 7/29/16 R17495 DEBIT ANTHONY WIANT RSE
Total Paid for BUILDING STANDARDS ADMINISTRATION
$1.00 $1.00
BSA:
Printed: Friday, July 29, 2016 4:10:33 PM 1 of 2
CRSYSTEMS
BOND
INFORMATION
ATTACHMENTS
CLTD -]
_
DESCRIPTION
ACCOUNT
QTY
AMOUNT
PAID
PAID DATE
RECEIPT #
CHECK #
METHOD
PAID BY
BY
WALL/FENCE - FIRST
101-0000-42404
0
$47.86
$47.86
7/29/16
R17495
DEBIT
ANTHONY.WIANT
RSE '
100 LF
WALL/FENCE - FIRST
101-0000-42600
0
$60.91
$60.91
7/29/16
R17495DEBIT
ANTHONY WIANT
RSE
100 LF PC
Total Paid for FENCE OR FREESTANDING WALL: $108.77 $108.77
BOND
INFORMATION
ATTACHMENTS
Printed: Friday, July 29, 2016 4:10:33 PM 2 of 2
' SYSTEMS
Bit) #
City of La Quinta
Building 8F Safety Division
Permit 78-495 Calle Tampico
La Quinta, CA 92253 = (760) 777-7012
Building Permit Application and Tracking Sheet
Project Address: y 5 - 6 9c) " � OwCncr's Name: �T�1 �y� f-bf ,i. a �a
A. P. Number:
Address:(-� 8 �' o C <-,
Legal Description:
City, ST, Zip: LOL (� Wk vl` u. a' S 3 O
Contractor:
Telephone: -
::.:;•;:.;;;:;:<.:r :.:::.;:: «.:;....
Address:
Project Description: �-
City, STI, zip -
1 :.. .
Tele h ne:.
p0
State Lic. # :
City Lie. #;
Arch.; Engr., Designer: .
Address:
City, ST, Zip:
Telephone:
n TY e- u an cY:
Constructiontructi P
State LIc. #:
Demo
Project ect hP (circle ircle one : New Add'n Alter' Repair o
Name of Contact Person:
Sq. Ft.: 2
#Stories:
#Units:
Telephone # of Contact Person:
Estimated Value of Project:
IJ Submittal Req'd
APPLICANT: DO NOT WRITE BELOW THIS LINE
Rcc'd . TRACMG PERMIT FEES
Plan Sets
Plan Cheek submitted
Item
Amoun
Structural Cafes.'
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person '
Plan Clieck Bal anc .
Title 2Q Calcs.
Plans picked up
Construct'
Flood plain plan
. Plans resubmitted
chanical
Grading plan
2" Review, ready for correctionsfissue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
li.O.A. Approval
Plans resubmitted
Grading
IN -ROUSE:-
'`d Rcyiew,ady for eorrcctionsrlssuc
Developer Impact Fee
Planning Approval
C ed Cont act Person
A.I.P.P.
Pub. \Vks. Appr
Date of permit issue
School Fees,
Total Permit Pecs
#4. HORIZONTAL REBAR
(USE BOND BEAM BLOCK)
6" OR 8" BLOCK
.. H..
HEIGHT FROM TOP
J #4 HORIZONTAL AT 32" MAX. O.C. HEIGHT FROM TOP'
OF FOOTING .' (USE BOND BEAM BLOCK) OF FOOTING
REVERSE
DIRECTION OF
HOOK ON EVERY
(� ..W,. -�
L(FOOTINGWIDTH)
OTHER REtiAli SEE TABLE "A"
H..
W,.
..9
L
H
{
VERTICAL
SEE TABLE "A"
SEE TABLE "B"
REINFORCEMENT
I
'29"#4
FOR REBAR SIZE
FOR REBAR SIZE I
20"
I'
5'
F6'
ANO SPACING
ANf) SPACING..
•
#4 @ 24" O.C.
(LGen aeonsi:. ceenra or c6j.';
U..ccar[rniw,IN c:F_ry If.1t aF Cli_J
: .FINISH GRADE
(1) - #4 REBAR
-- —a—}�-
Illi`(2) - #4 REBAR
SOME
� —111 1111
��a
CONTINUOUS 111ll-a :e F
4 i
REVERSE
DIRECTION OF
HOOK ON EVERY
(� ..W,. -�
L(FOOTINGWIDTH)
OTHER REtiAli SEE TABLE "A"
ALL FOOTINGS ADJACENT TO
SLOPES TO BE AT LEAST 5' TO
DAYLIGHT AS SHOWN BELOW.
a.
Qi..
tlO7TOM � •.
-or'
FOOTING
NOTES:
1) THIS DESIGN DOES NOT ALLOW GRADE DIFFERENTIALS OF
.MORE THAN 6".ON OPPOSING SIDES OFTHE WALL: THIS IS
NOTA RETAINING WALL.
2) FENCE HEIGHTS ARE REGULATED -CONSULT ZONING
REGULATIONS BEFOREBEGINNING CONSTRUCTION.
3) NO WATER COURSE OR NATURAL DRAINAGE SHALL BE
OBSTRUCTED.
4) GROUT ONLY THE CELLS CONTAINING REBAR. THIS WALL
1S NOT DESIGNED FOR ALL CELLS TO BE GROUTED.
5) ALL REBAR TO BE ASTM SPEC. A61.5, GRADE 40 MINIMUM.
6) ALL REBAR LAP SPLICES TO BE 24" MINIMUM.
7) ALL MASONRY UNITS TO BE ASTM C-90 GRADE N.
j 8) REBAR TO BE CENTERED IN MASONRY CELLS.
-k_ "W..
'(FOOTING WIDTH) I '
SEE TABLE -13"
4 G-
>1�ABLIF 8
H..
W,.
..9
L
H
W'
VERTICAL
4*
22"
REINFORCEMENT
51
'29"#4
#4'@ 48". O.0::
4'
20"
'#4 e 48" O.C.
5'
F6'
23"
#4 @ 48" O.C.:
29"
#4 @ 24" O.C.
ALL FOOTINGS ADJACENT TO
SLOPES TO BE AT LEAST 5' TO
DAYLIGHT AS SHOWN BELOW.
a.
Qi..
tlO7TOM � •.
-or'
FOOTING
NOTES:
1) THIS DESIGN DOES NOT ALLOW GRADE DIFFERENTIALS OF
.MORE THAN 6".ON OPPOSING SIDES OFTHE WALL: THIS IS
NOTA RETAINING WALL.
2) FENCE HEIGHTS ARE REGULATED -CONSULT ZONING
REGULATIONS BEFOREBEGINNING CONSTRUCTION.
3) NO WATER COURSE OR NATURAL DRAINAGE SHALL BE
OBSTRUCTED.
4) GROUT ONLY THE CELLS CONTAINING REBAR. THIS WALL
1S NOT DESIGNED FOR ALL CELLS TO BE GROUTED.
5) ALL REBAR TO BE ASTM SPEC. A61.5, GRADE 40 MINIMUM.
6) ALL REBAR LAP SPLICES TO BE 24" MINIMUM.
7) ALL MASONRY UNITS TO BE ASTM C-90 GRADE N.
j 8) REBAR TO BE CENTERED IN MASONRY CELLS.
-k_ "W..
'(FOOTING WIDTH) I '
SEE TABLE -13"
4 G-
>1�ABLIF 8
H..
W,.
..9
VERTICAL
REINFORCEMENT
3'
1
C...
#'4 @ 48" O.C.-
4*
22"
#4 @ 48".O.C..
51
'29"#4
Ca'48`O:C.'
6'
34i1
#4 @ 24'1'0.C:
Gf iECK 4ViTH T}jE.BuiL QIN.G_DEPARTMFN f O.
VERIFY;IF A BUILDING PERMIT.,lS..REQUfRED.
WHEN A PERIv1IT IS REQUIRED, THE FOLLOWING
INSPECTIONS ARE REQUIRED:
1) FOOTING: EXCAVATION TRENCH CLEAN WITH
STEEL IN Akin
AWAY FR M L t �
2) REBAR/. ,R T: N A
VERTICAL RE jtoA, 4r!T
3) F NAL; A PLACINGGR R GROUTt IS rE!QRVI O AI, Y
DECORATI E CAF (1�`AtIe �•STRUCTIOI V
'SEE PAGE 2 -FOR ADDITIONAL INFORMATION'..
DISCLAIMER;
ALTERNATE DESIGNS ,MAY BE POSSIBLE'
WHEN PROVIDED WITH AN .ENGINEERED
ANALYSIS. USE OF THIS STANDARD DESIGN tcEVG'.r`i,�'a
IS' AT THE USER'S RISK AND CARRIES 1,10
IMPLIED OR INFERRED' GUARANTEE AGAINST'' PHONE (760) 777-7125
FAILURE OR DEFECTS.
FAX (760) 777-701 1
FREESTANDING BLOCK -WALL
74�-495 CALLF, TAMPIGU
�1;A.OlI1N'I'A. (:`.L\I,11i012NIA 922S;i
IV/`)/2V19 CU�1'�1 UiGlll'.11f VLLUI�MEKf UF,fT. 1''AG F, 1 U1�2
FOC
REBAR PLACEMENT
ILLUSTRATION
DESIGNTARAMETERS:
ACTIVE SOIL PRESSURE (PSF) =30
PASSIVE SOIL BEARING (PSF) =150
COEFFICIENT OF FRICTION = 0.25
ALLOWABLE SOIL BEARING (PSF) =1 500
WIND = 80 MPH. EXPOSURE C
SEISMIC:
NA=1'3. NV= 1.6. Z=0.4. SOIL PROFILE=SD'
FOOTING OPTIO.N.B
YPICAL-)
3 AND BOND BEAM
JITH REBAR TO BE
ROUTED
;ROUT ENTIRE WALL - USE
IESH AS APPROPRIATE)
�, , \
-_ --• (TYPICAL)
jig tt
✓�
ALL REBAR SHALL HAVE A
MINIMUM OF 3" CONCRETE
COVER AT FOOTINGS
WESTERN RIVERSIDE COUNTY CODE UNIFORMITY PROGRAM
ot 4v
i�
FREESTANDING BLOCK WALL
'v fil T\\•
PHONE (760) 777-7125
78-1195 CALL[,'TAMPICU
LA C.)1IINTA, CALIPORNIA 2253
FAX (760) 777-7011
1(1/9/2014 CC11i hSIJ;a'fY 1)F:VI;1.O1'Af ta."I' UISIII'. 1•AC.ii 2 0R 2
P1
Google earth feet 600
meters 100
LIM
D
PA" 51 tHtat-
/
r
yr
P�wYs��'t'S 9lq lutio
Cl lY OF LA QUINTA
BUILDING & SAFETY DEPT.
A PR0VED
FOR CONSTRUCTION •
DATE -7 2 i,- BY �
.� � � L � . �F•"C' 0� � moi. ��.-� ► � � � � .L-�.... ,
P.O. Box 1504
LA QUINTA, CALIFORNIA 92247-15.04
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
IMPORTANT! NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has een submitted in your name listing yourself as the bu lder of the property
improvements specified A-6,6-6 8
We arerovidin t
p g you with anOwner- urldei Aclmowledgment 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 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 signs you understand or verify this information.
4,r 1. 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 property.
/2'. I understand building permits are not required to be signed by property owners unless they are responsible for the
ccrnsst'ruction and arenot 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
a�if from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my
4.1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
pe,,�rrAits and contracts.
A5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors and
the total value
�of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer"
� der state and federal law.
A46. I understand if I am considered an "employer" under state and federal law, I must register with the state and federal
�g71emment, 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.
A7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds sin le-.
g 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.
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
workriianship or materials.
AH. 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
Di Fisilon of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-
800-32 l-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors.
1.0. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the
party
ylegal l]y/. and finan'cia,Ily .responsible f9r proposed construction' activity at the following address:
AD,JI I - 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.
1 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I
h Iv 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 prbperty 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 ggencyis required to be presented when the permit is issued to verify the property
owner's signature.
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.
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby ho— ze-
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): G Wpb
Project Location or Address: '45 % 0 GQ
Name of Authorized Agent: "—T'- Tel No G Q 6 2 5 -� (7
EXi—
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
I
nformation 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. be pre red hen the permit is issued to verb the pro erty ner s signature.
Property Owner's Signature: Date: l
/9 i,