BWFE2014-107078-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: BWFE2014-1070
Property Address: 78970 SONESTA WAY
APN: 604151031 .
I Application Description: BLOCK WALL 40 LF
Property Zoning:
Application Valuation:
Applicant:
Qum&
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING PERMIT
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).:
(_) 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.).
(� 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 contracts for the projects with a contractor(s) licensed pursuant to
the Contractors' State License Law.).
(_) I am exempt under Sec. . B.&P.C. for this reason
Date:
Owner:
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 Na
Lender's Address:
Owner:
ANDREW CARRERA
, 92253
Contractor:
Llc. No.:
VOICE (760) 777-7125.
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 9/12/2014
. 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. . R.
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 LaborCode, I shall forthwitF
comply with those provisions.
Date:
Applicant:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFU:,
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 COD[,
INTEREST, AND ATTORNEY'S FEES.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT: Application is hereby made to the Building Official for a permit subject b
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. /j
I certify that I have read this application and state that the above i
I agree to comply with all city and county ordinances and state lay
construction, and hereby authorize representatives of this city t
mentioned I
ope for inspection purposes:1
Date: L Signature (Applicant or Agent):
DESCRIPTIONt,ACCOUNT,'�#
•• •
i�QTYsAMOUNT€�.;
PAID "
PAID DATE'
WALL/FENCE -FIRST 100 LF
101-0000-42404
0 $47.19
$47.19
9/12/14
„y PAID BYf,�CHECK
J. s.-t{f
#$
CLTD BY {
ANDREW CARRERA
DEBIT
R1135
MFA
u
rY kijDESCRIPTION�
,
R _Txy tACCOUNT�{ °i;.QTYf
Y:' AMOUNTS
{PAID
PAID DATE
WALL/FENCE - FIRST 100 LF PC
101-0000-42600
0
$60.06
$60.06
9/12/14
�;'," 4r� t PAID BY r gr
*. ,+ u
q � r METHOD * '
— §S 'x
' °r�RECEIP,T,#yy �4
41 sem. x� -
CHECK# ,
•ar-
44 CLT BY
ANDREW CARRERA
DEBIT
R1135
MFA
Total Paid for FENCE OR FREESTANDING WALL- $107.25 $107.25
TOTALS:
r
Description: BLOCK WALL 40 LF
Type: WALL/FENCE -
Subtype: Status: SUBMITTED
Applied: 9/12/2014 MFA
Approved: 9/12/2014 MFA
Parcel No: 604151031 Site Address: 78970 SONESTA WAYLA QUINTA,CA 92253
Subdivision: TR 23269
Block: Lot: 42
Issued:
Lot Scl Ft: 0
Building Sq Ft: 0 Zoning:
Finaled:
Valuation: $0.00
Occupancy Type: Construction Type:
Expired:
No.'Buildings: 0
No. Stories: 0 No. -Unites: 0
Details: 30LF OF 6' GARDEN WALL AND 10 LF AT 5' [CITY AND ANGELUS SPECIFICATIONS] PRECISION CONCRETE BLOCK SHALL BE COVERED
WITH STUCCO, PAINT, OR TEXTURED COATING WHERE VISIBLE FROM OUTSIDE THE PROPERTY. 2010 CALIFORNIA BUILDING CODES.
CONDITIOhl3 _
Printed: Friday, September 12, 2014 12:17:10 PM 1 of 2
sysrcnds
Printed: Friday, September 12, 2014 12:17:10 PM 2. of 2
srsTrMs
Bin #
City of LQ Quanta
Building 8t• SafetyDivision
P.O. Box 1504,78-495 Calle Tampico .
La Quinta, CA 92253 - (760) 777-7012...
Building Permit Application and Tracking Sheet
Permit #
.
Project Address: -
Owner's Name:
A. P. Number:
Address:
Legal Description:
City, ST, Zip:
Contractor
Telephone:
Address:
Project Description: v
City, ST, Zip:
iWin
Telephone:
:;;:<:;:.::,,.,.,.:,;:->: >k;.
State Lic. #.
City Lie. #;
.
Arch., Engr., Designer-
esignerAddress:
Address:
V
City., ST, Zip:
Telephone:
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Construction Type. ccupancy,:
Project type (circle one): New d n Alter Repair Demo
State Lic. #:
:::z -:::_>::z:» ::::.:::.:::.>.:<::;:
Name of Contact Person:
Sq. Ft.:
# ones:
# Units:
Telephone # of Contact Person:.
Estimated Value of Projec . rte' O C t:UCM
APPLICANT: DO NOT WRITE BELOW THIS LINE
# Submittal Req'd Rcc'd TRACKING PERMIT FEES,
Plan Sets
Plan Check submitted
Item
Amount
Structural Cates.
Reviewed, ready for corrections
Plan Cluck Deposit
Truss Cates.
Called Contact Person
Plan Check Balance.
Title 24 Cales.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2" Review, ready for corrcctions/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN If OUSE:-
'`" 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
UA
3�
CITY OF LA QUINTA
BUILDING & SAFETY DEPT-., -
T
'APPROVED
DATE
LU
4E
1, 9 77 VM 87
lot.,
Q) j ��.
TUY 4 4. Q9hA -
P.O. Box 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE 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.
Benefit/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 you:
name and you are personally responsible for the construction management, knowledge, workmanship, and completion of the job. Yoe
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 Low 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 hin
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 c -t
more than $500.00, the permit is taken out in your name and you are personally responsible for their employment requirement,
supervision, performance, safety and welfare while'on your property. WARNING: Cost savings benefit can turn to serious fmancifl
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 filed 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 a head 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.O. Box 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
PROPERTY OWNER'S PACKAGE
(760)777-7012
FAX (760) 777-7011
Disclosures & Forms for Owner -Builders Applying for Construction Permits
IMPORTANT! NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has bee submitted in your name listing yourself as the builder of the property
improvements specified at
We are providing you with an Owner -Builder Acknowledgment and Information erification 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 signify you understand or verify this information.
W-1-4 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.
-W-2--1 understand building permits are not required to be signed by property owners unless they are responsible for the
construction and are not hiring a licensed Contractor to assume this responsibility.
_K�3. I 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.
'. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
} permits and contracts.
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.
_K_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 io serious financial
risk.
V7'I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential
sciures 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.
k__8- I understand as an Owner-Builder if I sell the property for which this permit is issued; I may be held liable for any
financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
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.
kL(-W-I am aware of and consent to an'Owner-Builder building permit applied for in my name, and understand that I am the
party lell and finanAally responsible , for, proposed construction activity at the following address:
,��U _1/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.
. 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 rm mus a ompleted, and signed by the property owner and returned to
the agency responsible for issuing the per it. No opy of theproperty owner's driver's license, form notarization, or
other verification acceptable to the age cy is re t d to be esented when the permit is issued to verify the property
owiier's.signature.'
XSignature of property owner Date:
Note: The following Authorization Form is required to be completed by the property owner only when designating,
an agent of the property owner to apply for a construction permit for the Owner -Builder:
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize
the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an. Owner -Builder
Permit for my project.
Scope of Construction Project (or Description of Work): '
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above
information and certify its accuracy. Note: 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: k Date:
September 12,2014'
Dear Elaine,.
We are notifying you to let you aware that next week we -will he building a wall
along our property. We already have the.materials and permits from the city. We
are just making you aware so that you are not distraught when you. see work
being done on 'the edge of your property.
The city informed us that if you do not .want us to walk on. your property that
we would not be responsible for finishing your side of the wall. Since you have
to look at it as much as we do we thought it would only be fair to give you this
opportunity to allow us to finish your side of the wall at no cost to you.
Otherwise we cannot guarantee that your side -will have' a. nice finished. look.
One other.concern we have is when they go to dig the•trench for the
foundation, since the rocks lean up on the border, we don't want them to fall
into the, trench. A simple solution would be to allow us to move your rocks and
border back onto cardboard so it-will not disrupt your landscape. As soon as the
Wall is underway we -will return your landscape to its original state.
We have attached this simple form to ensure that we stick to our end of the of
the bargain. If you would be so kind to. sign and return this"to allow us to go
onto your side during the project it would be appreciated. If you decide that
you do not want to sign that is ok but we must remind-you that your side will
remain: unfinished. '
Thank you,
The Carrera Residence Y
1
September 2014
To whom it may concern;
I Elaine Simmons, will allow the Carrera family to build a wall between our
properties. I will allow them to walk onto my property and move our border. I
will. allow 3-5 days of work to be performed on my property'
WW
1 t- e Carrera famrly, w� e irrsta i g.a wail be , we n. ours an?Klame s
property. We willneed access'to her-property to ensure a clean finish, We will` ^�
return Elaine's property to its original condition. We will return all landscaping
to its original place-and condition within. 3-5 days from, startup of project.
1
ii
05/15/2014 09:50 !bb—
City
Of La QurriW
r
i Bt1
t7 a Safety Division
IP.O. Box 1
04, 78-495 Cage Tampico .
i
92253 - (760) 777.7012
Quirltdf9
Building PerrniC Application
and Tracking•Sheet
project AddtGss:
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at'B
NBe:
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A P. Numbrx
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ri, ST, Zlp:
jcgal Description'
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cicphorte' /
Contractor:
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Addro-=s:
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City, ST: ZP:
' Telophonc:
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Addr=:
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roject type (oltCle enc):
State Ur— tt:
Contact P
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atcd Vatue of Project:
fetephope
DO NOT 1A%Rt TE BEL is LINE
APMCAI
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09/15/2014 *109:: 0 760-7 7-9038 FEDEX OFFICE= 2029 rHut r,zi rJLJ
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�tIV'tt�►ti+�
P.O. BOX 1504 gUiLDINO & SAFETY DEPARTME-MT
LA Q INTA, CALIFORNIA 9 247-1504 .(760) 77,7-7012
78-d- 5 CALLS T I MPICO FAX (760) 7777011
LA Q. MIA,, CALIFORNIA 9 Z253
.I PERTY E7.' S P_A.CKA. E
It Q
& Forms for �Laer-B lders Applying for Construction Permits
canes ourself as the builder of the property
for a building pest, t has een submi in your name liatattg y
xx ificd at V:&/
Q you aware of your
g you with an wnarBuilder Aekno vlcd ehd Information Verification Form to make
iritic b having this permit iaeued in your name as the
,ad possible risk you may Y
We will not t e a building per,,* un J you have r-md, inittate'd your understanding of each provision,
turned this [o to us at oil
official a dress indicated- ,An agent of the owner oarutet execute this notice
nynn mr owned obtain the Prior aplrtoval f the pernvtting authoritY,
CM W D'J'
� frtom.......,_ - -
Read anti irri 1 each stotam t Below to ignifyYau understand or verily this i ormanon.
stand a fr t practice o unllcensed persons 'i3 to bave the property owner obtain an "
Ownet-Euildei
owoor ie providing his or iter Own labor and material personalty. I, as
:that erroneous y implies tha the prop p injuries sustained by an uriticensed person
der, tray be hold liable and bjact to se 'ovs financial risk fez anynot rovide coverage for those
employae3 ft working o MY pr MY homeowner s insurance maY P
Villfully aoting as an owner -1 riil.der and 0 m aware of the limits of my insurance coverage for injuries to %vorkors
ata ase not rewired to be signed by property owners �css they art r Vonvibls for the
rstand buil ' permits
ad are. not Kirin a licensed Contractor to umo this respobAbiliry.
rstand as an ` or -Builder' I I am the re 1ponsiblo party of record ou the permit i understand that I may protect
otcntioi financial risk by >iirvdg a licensed Contractor and baving the pe YWt fiiled in hl r ber name instead of my
l
rstand Contxac ors are mquir by law to c licensed and bonded Ga California rued to list their license numbers on
ontram
[ un erstand if 1 errs oy or otherwi a engage parsons, other than California licensed Contractors, and the total value
;ons*uction is at ]cat five hundred dollars ($5I 0), including labor rind materials, I MAY be considarcd an "employer"
tate rid federal law.
I understand if I considered aIL "1nTloyer under state and fcdcml lav;, I must register with the stato acid federal
Ment withhold payr 11 taxes provide worker ' compensation disability insumce, had contribute to unentploymerlt
rsation for tach " e loyec"�1 als( renders m}i failure to abide by three laws n12y subject we to serious filtancial
I
,erstand under miu+ Car tractors' SU to Lice= IAw, nn Owner -Builder who builds Single-family residential
isnot legally I ulldtlterx�w �tb the int t to offer them for sale, unless all work' is porfotmied by licensed
rs and the number of etructuFes does nol exceed four within any calendar year, of all of the work is performed
ct with a lictlis d general budding Con tot.
09/15/2014 09:
I erst(
financial '*• p�i
�vnrlcrrl3nsh- or
DOM
Service,
1
Division
500- .21-
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try �
760-7177-9038
as an 0wne Builder if I s
injuries fined by any
ttlJtn urrlLt' zu/q
;ll. the pro fur which this P> ma tt is issued, I may be held liable for any
11. the pro owners) that result from any latent aoastruetion defeats in the ,
subse
ttr
obligations as an "employer" from the Internal Revenue
I. I may obta ranre t tion Tegar g Y S p ts, and the (,lnlifornia
e California Dc sztmcttt of Benefit Payrncn CSLB at 1 -
States Small Business n nistzatlon,
al pccidcnta_ I also under I may c tact fire California Contractors' State Lic,:ase: f3oatd ( .
d con�otors.
52) or wWW. lb.ca.gov for ore ►afo tion about liecnSe
tand that ad the
of and coryt to on Own r -Builder b ding Pcm» t applied. for in my Warne, attd undcra
Ad financially Tro/ si le for Pro -Posed Nc ction activity at the following
t.
le 1 and mancial]y r spotlsible for this proposed con9tzll�on activity, I will abide by 1111
1. I e:dmt, as the P €a �' it as to ors.
a plicab c laws hand regnirorrK r that govern wncr-DuildJ�lts as,+M mp y
1.2 I to notify the i uer of this for immedtnt�ly of any additlom, deletions, or changes m ?r�Y of ►�tformad°n 1 +
ceesed contra rs arc re ated by laws designed to protect the public. If you cotliraet ovith
ave p ded on this form. L° be unable to assist you with any fintnacial loss
Safi OU ovha 4eks riot have a l cense, the CO trQCtaTS S e Lic"1SO B Imiicemed Contractors rimy be in civil court, It is Also
you rut Iustai�► as a result of complaint. our'01dy re dY Pte.while firm is
impm% t for you to understan that ii an un1T dam . °� you obra>n ator Or loyc-C of perutit asthat Owner .Builds ml# wishl ochitc C ntractor'
on your Prop , you may be old liable fo I a9 hosed and th® status of their workers'
you wit be r not
for v KY1119 whethar m' not tho a Contractors are properly
compo tion sural cc eov ge.
e owner And returned 'to
Before alDrtil Ing permit can be iasned, t%S form
NnteY3 roe compheproted p ny`own by
the
i e is license, forst notarization, or
the apt ncy r ponsible for is wing care pe p f �'
other a, on acceptable to the is requir presented, whdn the permit is issued to varyy t>,e prope;rty
owner's signre.
sipab of 1rcmty ov Date;
Note: 177
an U 4t
the
of
.tr penalty of pi qj"ury that I att� the pzop14 o for the address listed above and I personally filled out the above
tnd ce=rtify its a curacy. Not . copy of t a e 's drivers license, form notarisation, or other v,3riftcntion
t the ugoncy 0 equine 8 )recanted tivjr i th permit is issued to verify the pro �t1' owner's signottere.
ner's Sigoatur � I Date:
i
is
to be completed by the property o,&%8r otady when designating
Mowing Authori2es'ion
ke property owner
Fort requind
to apP1ylfnr a 00?W
ction.pemU for the Owner-Bui'ldet'•
p�g0
Notice to prop
O AGE
uty Owner, t execution
O (T O P U'� $ authort�,e
f oe�lticb I understand is my Personal responalbllrty, I hereby
file the documents necessary to obtain an Owneu-lguildcr
persons) to a
as mY Hgent(r to apply f r,
sip, and
project
Btrvution Proje
:J
dp (or Dcsoon of Work',:
L o
iE"J L
Z'
5 (i
r
ion or Address
v1u-t0 a
�6a 27 ��fO
Tel No(
horized Agent-
uthorized Agel
it M-00 1 iW�
�� G�cf G� • Z Z�J
.tr penalty of pi qj"ury that I att� the pzop14 o for the address listed above and I personally filled out the above
tnd ce=rtify its a curacy. Not . copy of t a e 's drivers license, form notarisation, or other v,3riftcntion
t the ugoncy 0 equine 8 )recanted tivjr i th permit is issued to verify the pro �t1' owner's signottere.
ner's Sigoatur � I Date:
i