10-0065 (RR)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: 10-00000065
Property Address: 46560 CAMEO PALMS DR
APN: 643-182-009-52 -2117
Application description: RE -ROOF
Property Zoning: LOW DENSITY RESIDENTIAL
Application valuation: 4500
Applicant:
Ti -ht 4 4 Q"
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Architect or Engineer:
A/0—
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
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 ap cant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
1 lel 1, 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 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.).
1 _ 1 I am exempt under Sec. , B.&P.C. for this reason
Date: 1 /'(,gyp/IV - -Owner:
CONSTRUCTION LENDING AGENCY
Lhereby 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:
LQPERMIT
Owner:
SELLERS RICK
Contractor:
Owner 1rl
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
i
Date: 1/26/10
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 su je to the workers' compensation provisions of Section
pp 3700 of the Labor Col I
1""
fon it c mply with those provisions.
Date:)gL&4 &W Applicant:
WAR IN : 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 1 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 buildi construc2iva hereby authorize representatives
of thisunty o enter upon the above-mentioned property rcn pecies.
Date: ` hG Signature (Applicant or Agent):
Application Number
. . . . . 10-00000065
Permit . .
. RE -ROOF
Additional desc .
Permit Fee . . .
. 30.00 Plan Check
Fee
.00
Issue Date .. . .
. Valuation
. . .
. 0
Expiration Date .
. . 7/25/10
Qty Unit Charge
Per
Extension
BASE FEE
30.00
- ----------------------------------------------------------------------------
Special,Notes and
Comments
RE -ROOF PER 2008 RESIDENTIAL
COMPLIANCE
AUGUST 2009.
----------------------------------------------------------------------------
Other Fees . . .
. . . . . . BLDG STDS ADMIN (SB1473)
1.00
Fee summary
-----------------
Charged. Paid Credited
----------------------------------------
Due
Permit Fee Total
30.00 .00
.00
30.00
Plan Check Total
.00 .00
.00
.00
Other Fee Total.
1.00 .00
.00
1.00
Grand Total
31.00 .00
.00
31.00
LQPERMIT
Bin #
City of La Quinta
Bulling 8t: Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
Project Address:0'\HFO P/-\ -t
Owner's Name:
A. P. Number:
Address:
Legal Description:
City, ST, Zip: (
Contractor: 11) L&
Telephone:
Project Description: RE —kop
Address-.
City, ST, Zip:
Telephone:`
City Lie. #;
State Lic. # :
Arch., Engr., Designer
Address:
City, ST, Zip:
Telephone:
' .. A.
'?: ? >.
Construction T ype. Occupancy:
State Lic. #:
Project type (circle one): New Add'n Alter Repair Demo
Sq. Ft: # Stories: # Units:
Name of Contact Person:
Telephone # of Contact Person: Estimated Value of Project: 11 5�,10
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rec'd
TRACKNG PERMIT FEES
Plan Sets
Plan Check submitted Item Amount
Structural Cities.
Reviewed, ready for corrections Plan Check Deposit
Truss Cala.
Called Contact Person Plan Check Balance
Tide 24 Cales.
Plans picked up Construction
Flood plain plan
Plans resubmitted Mechanical
Grading plan
2" Review, ready for correctionstissue Electrical
Subcootactor 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 correctionslissue Developer Impact Fee
Planning Approval
Called Contact Person A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
,Prescci tine Certificate of Compliance: Residential CF -IR -ALT
ResideWial.41teralions Pae 1 of 5)
Project Name: �� LEOIN �G�� `QD Climate Zone # # of StoriesF7 I
General Information
Site Address: q&5 GhbKl� PALM6
Enforcement Agency:
Date: it U
Building F\ peSingle f=amily ❑ Multi Fantil\
Circle the Front Orientation: N. F. S&or degrees(2
ttProject
Conditioned Floor arra (CFA): 1� % Z
T� pe: Alterations ❑ En%.elope ❑ Fenestration ❑ Root' C1 HVAC
Assembl\ Name
Replacement or Change Out ❑ Duct Replacement ❑ �\ ater Heater
NOTE: This forst is not to be used for Vewly Constructed Buildings or Additions
lasulation Values For Opaque Surfaces tfur- f urrhn use the .class and Furring Strips Construction table below;
Assembl• .Alteration
❑ Opening of framed cavity alone .Iherutirut\ that involve the opening of the (ruts d cavity Oct %Vail. ce,hn,g. or floor must install (lie
mandatory ntirtimun, insulation value per., l �t] 1;> the altered assentbh I'M in (ohuttns A - ( and enter mandator insulation value in „lttttt,t !!
❑ Replacement of entire assembly - Replacement ul an entire ,,all. ceiling. or floor assembh• requires the installation of Component
Package- D insulation values in Table 1 iJ-C. bill to Columns A -J.
Opaque Surface DetailS For the furred portioned of Mass Walls see Furring Strips Construction Table below.
Furring
Furring
A B C D E F G I I 1 J
Proposed SeeNate
Standard Values From JA3 Table
L �1
Proposed Properties of Masonr% and Concrete
Framing Thickness. Framed Continuous
JAd Proposed
Tag.,
Assembl\ Name
Material Spacing. U- JA -t -Fable Cavitv Insulation_
Assembl\ Assembl\
IDS
or T\ e'
and Sive- or Other' factor' Number' R -\alae`' R -Value
Cell Values l' -factor'
Final
Mass Name or J \ 1 1 ably =
_ -
_
_
= _ -
\"ole: For furredassemblies. crccountirtq for Connruuous /rrsu/anon R -value. see Page J.44-3 and Equation 4-1. use the uses unci
Furring Construction table belo\r.
1. For Tag ID indicate the identification name that matches the building plans.
'. Indicate the .I ssembly \ume or hpe: Rool"Ceilit{g. II -alts. Floors. Slabs. Crawl Space. Doors and etc... Indicate the 1 - rate type. and St_e. Fur
1600d..Iletal.Metal /3uildings. Mass. enter '.\-t.-'.r/i. or etc .. see J44,16r other possible frame n pe assemblies
3 Enter the thickness. for mass in inches or Spacing heti, een framing members enter: 16 "or 24 -0( : nr Other 1nr all other assembl_i description
such as Concrete Sund%cic•h Panel. .Speurdre! Panel. Logs. Stra%v Bale Panel and etc- ...
4 Based on the Climate Zone. enter the S7andurd I -/actor from Table 131-13. Cor D f2rr each dlflerent assentblt \ cline or h_ pe.
?. Enter the Tulle number that closely resembles the proposed assembi'.
6. Enter the R -value that is being installed in the ,raft cuvify or benreen the fronting: othe"-ise, enter "(J
- Enter the Continuous Insulation R -value for the proposed assembly: otherwise. enter "0".
S. Enter the row and column of (lie (.-!actor• vutue hosed on Column F Table \tonber and enter the .Issembly ( lartor in Column J
9. The Proposed Assernhty C. factor. C011111117 .1. uursi he equal to or less than the Standard C factor in Column E m colnplv-
comply-
Strips Construction Table for Mass Walls OnIV
A B C D E
F G H 1 J K
L �1
Proposed Properties of Masonr% and Concrete
.Added Interior or Exterior Insulation
Walls From Reference
in Furring Space from Reference
�
Joint Appendix Table 3.3.5. 4.3.6, 3.3.7
Joint Appendix Table 3.3.13
Final
Mass Name or J \ 1 1 ably =
_ -
_
_
= _ -
' =
\•.rmbh
Thickness T\
>y
—
_ _
l factor- Comment
- i —
1
i------
i i
I
i �
Registration .\umh\•r. _ Regivro(ion late Tim(, _ !t1 -.RS Provider.
200S Residential C'onipliarrce Forme Allgiw 2009
PrescA i tive Certificate of Com fiance: Residential CF -IR -ALT
Residential Alterations age 2 of 5
Project Name: Climate Zone # # of Stories
r 21E- 15 I r
[Nass and Furring Strips Construction (footnotes) 1
1. Indicate the type of assembly to include: Hollow Unit Masonry Walls, Solid Unit Masonry, Solid Concrete Walls, Etc. Additional assemblies can
be found Reference Joint Appendix JA4.
2. This is the U -Factor based on the thickness of the assembly in inches.
3. The R -value of the insulation to be added on the interior or exterior of the assembly.
4. The Calculated R- Value is the R -value of the furred out section of the assembly.
5.-6. The Final Assembly is calculated using Equation 4-2 or Equation 4-4of the Reference Joint Appendix JA4. The equation is the inverse of Column
O added to Column l. Column K is the inverse from column J.
7. Insert the calculated U -factor value on to the Opaque Surface Details in Column J
FENESTRATION PROPOSED AREAS
❑ Replacing window atone — Replacement windows shall meet the U -Factor and SHGC Value requirements of Component Package D in
Table 151-C. The Total Fenestration and West facing Area requirements are not applicable.
❑ Adding 501112 or less of window area — Newly installed windows shall meet the U -Factor and SHGC Value requirements of Component
Package D in Table 151-C.
❑ Adding more than 50ti1' of window area — Newly installed windows shall meet the U -Factor and SHGC Value and the Fenestration
Area requirements of Component Package D in Table 151-C. Complete the Altered Fenestration Allowed Area Table on Page 2 of the CF- IR -ALT
Orientation
Existing
Fenestration
Fenestration Type and Frame
window, Glass Door or Skylight)
(North, East,
South, West)
PropsedArea' Maximum
-factor"
Maximum NFRC or Default
SHGC'';' ° Value
Fenestration
Area
Fenestration Allowed Proposed Area'
Dwelling
CFA
Area
Removed
Area Added A x B) (E -D) + C
Total Fenestration Area
ftz
I. Fenestration area is the area of total glazed product (i.e. glass plus frame). Exception: When a door is less than 50.0 glass, the fenestration
area may be the glass area plus a "2 inch frame " around the glass.
2. Enter value from Component Package D Requirements in Table 151-C.
3. Actual fenestration products installed and as indicated in CF -6R -ENV Form shall be equivalent to or have a lower U factor and/or a lower
SHGC value than that specified on the CF -1R ALT Form.
4. Submit a completed WS -3R Form if a reduced SHGC is calculated with exterior shading.
5.ffapplicable at this stage enter "NFRC" or NFRC Certified windows or are CEC "Default " values found in Table 116-A or B.
ALTERED FENESTRATION ALLOWED AREAS (Complete If more than SOW of fenestration is added)
Registration Number: Registration Date,Time: HERS Provider:
2008 Residential Compliance Forms
August 2009
A
B
C
D
E F G
Allowed
Existing
Fenestration
Total Area
CFA of Entire
% of
Fenestration
Area
Fenestration Allowed Proposed Area'
Dwelling
CFA
Area
Removed
Area Added A x B) (E -D) + C
Total Fenestration Area
ftz
.20
—
West Fenestration Area
(Required In
.05
CZ's 2, 4 & 7 -15
1. West Fenestration Area includes west -sloping skylights and any skylights with a pitch less than 1:12.
2. West facing glazing area removed cannot be "counted** twice. - In order to distribute the west glazing area removed to the other orientations.
input the west glazing area removed in the Total Fenestration Area row, column D.
3. Include the Proposed Area of the West facing fenestration in both Area columns below.
4. To meet compliance. the Proposed Area must be less than orequal to the Total Allowed Area or BOTH the Total and West Fenestration Areas.
Registration Number: Registration Date,Time: HERS Provider:
2008 Residential Compliance Forms
August 2009
Prescriptive Certificate of Compliance: Residential CF -IR -ALT
Residential Alterations Page 3 of 5
Project Name: Climate Zone $1 # of Stories
INCE RO&F k5 I l .
ROOFING PRODUCTS (COOL ROOFS) §151(1)12
When the area of exterior roof surface to be replaced exceeds more than 50% of the existing roof area, or more than 1,000f?, whichever is
less, the new roofing area must meet the roofing product "Coot Roof' requirements of §152(b)1 Hi, 152(b)IHiI, or 152(b)1 HIM
Check applicable alternative or exception below if the roof alteration is exempt from the roofing product "Cool Roof' requirements. Note: If any
one of the alternatives or exception below is checked, the Aged Solar Reflectance and Thermal Emittance requirements for roofing products in
§118(i) are not applicable. Do not fill table below.
❑ Cool Roofs Not Required in Climate Zones 1-12, 14, and 16 with a Low Sloped. Less or 2:12 pitch.
❑Cool Roofs Not Required in Climate Zones 1 through 9 and 16 with a Steep -Sloped Roofs (pitch greater than 2:12) and product unit weight less
than 5lb/ft2.
Alternatives to §152(b)IHi and §152(b)Hii, Steep -slope roof (pitch > 2:12)
❑ insulation with a thermal resistance of at least 0.85 hrft •°FBtu or at least a 3/4 inch air -space is added to the roof deck
over an attic; or
❑ Existing ducts in the attic are insulated and sealed according to § 15l(f)10; or
❑ In climate zones 10, 12 and 13, with 1 ft2 of free ventilation area of attic ventilation for every 150 ft2 of attic floor area, and
where at least 30 percent of the free ventilation area is within 2 feet vertical distance of the roof ridge; or
❑ Building has at least R-30 ceiling insulation; or
❑ Building has radiant barrier in the attic meeting the requirements of §151(f)2; or
❑ Building has no ducts in the attic; or
❑ in climate zones 10. 11. 13 and 14, R-3 or greater roof deck insulation above vented attic.
Exception to §152(b)iHiii, Low -slope roof (pitch <_ 2:12)
❑ Building has no ducts in the attic.
Other Exceptions
❑ Roofing area covered by building integrated; photovoltaic panels and solar thermal panels are exempt from the below Cool Roof criteria.
❑ Roof constructions that have thermal mass over the roof membrane with at least 25 Ib/ft2 is exempt from the below Cool Roof criteria.
Note: If no CRRC-1 label is available, this compliance method cannot be used, use the Performance Approach to show compliance, otherwise.
Check the applicable box below if Exem t from the Roofi2& Products "Cool RoofRequirement:
Roof Slope
Product Weight
Product
Aged
Solar
Thermal
Product IID Number'
< 2:12 > 2:12
< 5lb/ft2 > 51b/51b/112%T
2
Reflectance
3,4
Emiit�tance
SRI
�/C�(R%R�C
05q0"V 000 a q
O
13
�7'1�1.i�LbS
[34
•M��7 � 1. I
�� l
o
a
a
o
E14
o
a
a
o
W
o
a
o
0
04
0
0
o
a
E34
1. The CRRC Product ID Number can be obtained from the Cool Roof Rating Council 's Rated Product Directory at www cootroofs.ore/n oducts/search.W
2. indicate the type of product is being used for the roof top, i.e. single ply roof asphalt roof. metal roof. etc.
3. /f the Aged Reflectance is not available in the Cool Roof Rating Council's Rated Product Directory then use the Initial Reflectance value from the same
directory and use the equation (0.2+0.7(pi„irial — 0.2) to obtain a calculated aged value. Where p is the Initial Solar Reflectance.
4. Check bot if the Aged Reflectance is a calculated value using the equation above.
5. Calculate the SRI value by using the SRI- Worksheet at hip:!/watv.energr ea. yovliitle24i and enter the resulting value in the SRI Column above and attach atopy of
the SRi- Worksheet to the CF -IR.
To apply Liquid Field Applied Coatings, the coating must be applied across the entire roof surface and meet the dry mil thickness or coverage
recommended by the coatings manufacturer and meet minimum performance requirements listed in § 118(i)4. Select the applicable coating:
0 Aluminum -Pigmented Asphalt Roof Coating
113 Cement -Based Roof Coating
Other
Registration Number: Registration DatelTime:
2008 Residential Compliance Forms
HERS Provider:
August 2009
Presr:ri tive Certificate of Compliance: Residential CF -IR -ALT
Residential Alterations Page 5 of 5
Project Name: Climate Zone # # of Stories
R -(z Ip _ - r >` is I
HERS VERIFICATION SUMMARY The enforcement agency should pay special attention to the HERS Measures specified in this
checklist below. A completed and signed CF -4R Form for all the measures specified shall be submitted to the building inspector before final
inspection.
Duct Sealing & Testing HERS verification is required for this measure.
0 YES 0 NO YES: In Climate Zones 2 and 9-16, if more than 40 linear feet of new or replacement ducts are installed in unconditioned
space, the ducts are to be sealed per §I52(b)1Dii and the newly installed ducts are to be insulated per §15l(f)10.
O EXCEPTION: Existing duct systems that are extended, which are constructed, insulated or sealed with asbestos.
0 YES 13 NO YES: In Climate Zones 2 and 9-16, if the existing space -conditioning system (HVAC equipment and ducting) is replaced, the
ducts are to be sealed per §I52(b)IDi.
0 YES 13 NO YES: In Climate Zones 2 and 9-16, if the existing HVAC equipment is replaced (including the replacement of the air handler,
outdoor condensing unit of a split system, cooling or heating coil, or the furnace heat exchanger) the ducts are to be
sealed per § 152(b) I E.
0 EXCEPTION: Duct systems that are documented to have been previously sealed confirmed through HERS
verification in accordance with procedures in the Reference Residential Appendix RA3.
17 EXCEPTION: Duct systems with less than 40 linear feet in unconditioned space.
O EXCEPTION: Existing duct systems constructed, insulated or sealed with asbestos.
Refrigerant Charge -Split System HERS verification is required for this measure.
0 YES 17 NO YES: In Climate Zones 2 and 8-15, when the existing HVAC equipment is replaced (including the replacement of the air
handler, outdoor condensing unit of a split system A/C or heat pump, cooling or heating coil, or the furnace heat
exchanger) a refrigerant charge measurement shall be verified per§152(b)IF.
Central Fan Integrated (CFI) Ventilation System and Fan Watt Draw
The ventilation requirements of § 150(o) do not apply to existing residential homes.
Ducted Split Systems -Air Conditioners and Heat Pumps: Airflow HERS verification is required for this measure.
O YES 13 NO YES: In Climate Zones 10 through 15, when the existing space -conditioning system (HVAC equipment and ducting) is
replaced, the airflow and fan watt draw shall be verified r 152 b lCi to meet the requirements of §151( 7B.
Documentation Author's Declaration Statement
• I certify that this Certificate of Compliance documentation is accurate and complete.
Name:
Signature: e ipt
Company:
Date:
ll (U
Address:146,F3
If Applicable0 CEA or O CEPE
�j(7 P&' . s
(Certification #):
City/State/Zip:� Gk 1 111
Lb,,U itJ
Ph3t S () S
Responsible Building Designer's Declaration Statement
• 1 am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the building design identified on
this Certificate of Compliance.
• 1 certify that the energy features and performance specifications for the building design identified on this Certificate of Compliance conform
to the requirements of Title 24, Parts I and 6 of the California Code of Regulations.
• The building design features identified on this Certificate of Compliance are consistent with the information provided to document this
building design on the other applicable compliance forms, worksheets, calculations, plans and specifications submitted to the enforcement
agency for approval with this building permit application.
Name: Q'6
Signature:
Company: 55 60
ate:
,
Address: _ j -
�YPhone:
License:
City/State/Zip:
1, OtWT4 a_\ g22iS3
_f b - 91:�0 - Cr'q5
For assistance or questions regarding the Energy Standards, contact the Energy Hotline at: 1-800-772-3300.
Registration Number: Registration Date -Time:
2008 Residential Compliance Forms
HERS Provider:
August 2009
Mnmev"N�ffll
t /
t �
P.O. BOX 1504
LA QUtNTA, CALIFORNIA 92247-1504
7$-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 Pei rmits
�1l�aPifl.+RT'. NT! NOTICE TO PROPERTY OWNER
Dear Property Owner.
An. application --for- a building permit has been submitted in yo& name listing yourself as the builder of the property
improvements specified at
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 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.
O PER'S ACKNOWLEDGMENT AND VER KATION OF INFQRMMN
DIRECTIONS: Read and initial each statement below to signify you understand or verify this information -
U -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.
V__ 2- I understand building permits are not required to be signed by property owners unless they are responsible for the
(ionstruetion and are not hiring a licensed Contractor to assume this responsibility.
0-3. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect
thyself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my
own.
U_4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
permits and contracts.
5. 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"
under state and federal law.
6. 1 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
nsk
7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential
S,Vcltures 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.
M
8. 1 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.
U-9. I understand 1 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 (CS -LB) at 1-
800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors.
10. I 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:
1. 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. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the infornWiOn 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 notaritaiion, 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 (1
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 1 understand. is my personal responsibility, l hereby authorize
the following person(s) to act asmy agents) 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: 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: