11-0987 (RER)10
P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
11-00000987
Property Address:
53235 AVENIDA VILLA
APN:
774-063-024-12 -000000-
Application description:
REMODEL - RESIDENTIAL
Property Zoning:
COVE RESIDENTIAL
Application valuation:
450
Applicant: Architect or Engineer:
04clIJr�12 �k
�.
4
BUILDING & SAFETY 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 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 applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
1 _ 1 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 town 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 I, as owner of the property, am exclusively contracting with licensed contractors to construct the project. (Sec.
7044, Business and Professions Code: 'I he Cohtr9Ct6P5' State LICense Law WeS 1101 -apply w an uw11ei ui
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 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 ISec. 3097, Civ. C.).
Lender's Name:
Lender's Address:
LQPERMIT:
Owner:
PINTER MICHAEL S
50540 CYPRESS POINT
LA QUINTA, CA 92253
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date:. 9/15/11
Contractor: ��++� t1l
IOwnerU %.�11 1 3L
r
CITY OF LA AUiNTiI!
-----------------------------------------------
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
_ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
issued.
I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor
Code, for the performance of the work for which this permit is issued. My workers' compensation
insurance carrier and policy number are:
Carrier Policy Number
I certify that, in the performance of the work for which this permit is issued, I shall not employ any
person in any manner so as to become subject to the workers' compensation laws of California,
and agree that, if I should become subject to the workers' compensation provisions of Section
Q / 3700 of the Labor Code, A shall foth comply with those provisions.
Date: l —l� Applicant:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL' PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($100,000)• IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the
wuJlJ�na
-J vt fbRP. ave th'a appliaatian.
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 building construction, and hereby authorize representatives
.of this county to enter upon the above-mentioned propertly�'l four insp�rposes.
;Date: "1 � ` / Signature (Applicant or Agent): X J�
—V
Application Number . . . 11-00000987
------ Structure Information SLIDING GLASS DOOR CHANGE OUT
-----
Other struct info : . . . . CODE EDITION
2010
Permit BUILDING PERMIT
Additional desc .
Permit Fee . . 15.00 Plan Check Fee
9.75
Issue Date Valuation
. . 450
Expiration Date 3/13/12
Qty Unit Charge Per
Extension,.
BASE FEE
15.00
------------
Special Notes and Comments
- -
-
CHANGE OUT EXISTING SLIDING GLASS DOOR
TO SINGLE GLAZED SWINGING DOOR AT NORTH
SIDE OF RESIDENCE. WORK COMMENCED PRIOR
TO PERMITTING REQUIRED TO BE EXPOSED FOR
INSPECTION -CODE CASE: 11-2500 [GM)
2010 CALIFORNIA BUILDING CODES.
September 15, 2011 9:44:44 AM AORTEGA
----------------------------------------------------------------------------
Other Fees . . . . . BLDG STDS ADMIN (SB1473)
1.00
ENERGY REVIEW FEE
.98
Fee summary Charged Paid Credited
-------------------------------------
Due
--------------------
Permit Fee Total 15.00 .00 .00
15.00
Plan Check Total 9.75 .00 .00
9.75
Other Fee Total 1.98 .00 .00
1.98
Grand Total 26.73 .00 .00
26.73
Bin #...., .
City of .La Qu►nta
Building & 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: S ��-3
Owner's Name:
A. P. Number:
Address:
Legal Description:
City, ST, Zip: �a s
L � c�
Contractor:
Telephone' 7%U St 1:5&) %
:•::;.>x:.:::.u.s>.:
.•�;.>: :;. •`,cap a�;�:,z
Address:
Project Description: r e MD tae ✓Y0 /4F-11 4- z kN— '
City, ST, Zip:
Q� ✓✓t 2J� o
Telephone:
:�c.: :;;;;�:;:>>r
State Lic. # : City Lic. #:
Arch., Engr., Designer:
Address:
City, ST, Zip:.
Telephone:
State Lic. #:v.�
•> --' a' ��
�tiv:y s�%zs%A ,
-"`��an
Construction Type: Occupancy:
tyPt (circle one): New Add'n Alter Repair Demo
Name of Contact Person:
Sq. Ft.:
# Stories:
# Units:
Telephone # of Contact Person: 6 o O 1 (o% % Estimated Value of Project: r
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Recd
TRACING PERMIT FEES
Plan Sets
Plan Check submitted Item Amount
Structural Cales.
Reviewed, ready for corrections • Plan Check Deposit
Truss Calcs.
Called Contact Person Plan Check Balance
Title 24 Calcs.
Plans picked up Canstruction
Flood plain plan
Plans resubmitted Mechanical
Grading plan
2'0Review, ready for correctionsrissue EI drical
Subcontactor List
Called Contact Person \ PYimbing
Grant Deed
Plans picked up
H.O.A. Approval
Plans resubmitted Grading
IN HOUSE:-
Review, ready for correctio ssue Developer Impact Fee
Planning Approval
Called Contact Person I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
'dotal Permit Fees
DOC # 20114"6917
09/14/201108:00 AM fees: $21.00
page 1 o1,3 Doc T Tax Paid
Recorded' in Gaal Records
RECORDING REQUESTED EV County of Riverside
Larry W. Ward
Assessor, County Clerk & Recorder
AND WHEN RECORDED MAiL TO;
MICHAEL S. PiNTER —This docnnient was electronicaily submitted
to the County of Riverside for recording""
50540- Cypress Point Receipted by: YSEGURA
La Quiht:4, CA 92253
GST DEED
TTTLE ORDER NO. T4106618631 ESCROW NO..,APNN0::.7,'4 063-024-3
'Our File No. ANA201120378 -_ _
THE UNDERSIGNED GRANTOR(s) DECLARE(s)
DOCUKWTARY TRANSFER TAX is 5123.20 CiTY TAX $
r ® Computes on full value of property conveyed, or `
❑ Computed on full value less value of liens and encumbranm remaining at time of sale"
® HninOA tet4aren. City of LA QUINTA
• FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
HOUSEHOLD FINANCE CORPORATION OF CALIFORNIA, hereby GRANT(S) to
MICHAEL S. PINTER, AN UNMARRIED MAN.
a
the following described real property in the City of LA QUiNTA, County of RIVERSIDE, State of Cslifamia:
See Attached Exhibit A.
Dated:
" HOUSEHOLD FINANCE CORP RAT1ON OF
CALIFORNIA
»Y' Esther E I h6r P - mcun a
r
STATE OP CALIFORNIA
COUNTY OF LOS ANGELES) ss.
On , before me , a Notary
(insert name and title of the officer)
Public, personally appeared _
wbo proved to me on the basis of satisfactory evidence to be the persons) whose na s/are subs®ibed to the within instrument
• and acknowledged to me that he/she/they executed the same in his/her/their nzed eapacity(ies), and that by his/her/thcir,
signature(s) on the instrument the person(s), or the entity upon be which the person(s) acted, executed the instrument
1 ce 14 under PENALTY OF PERJURY under of the State of California that the fbmping paragraph is true and correct
WITNESS my hand and offic'
(SI("iNATURF OF NOTARY) ,SEAL
x
OMR Aneroval No 2502-0265
A. Settlement Statement (HUD -1)
Printed On: 08!72!2077 05:98 PM
-TM
1. E] FHA 2. O' RHS 3. E]CM11. Unit.
4• ❑ VA S. (3 Core, It.
6. File Number.
7010818831
7. Loan Number:
CASH
. M ort age Insurance Case #:
C. dots: This form Ls Nrrdshe0 ta gNe you a statement of actual settlement cosh. Artqunts paid to and by the settlem M agent ere shown. Mems marked'(P•o.c)' were paid
outside the closing they are shown hem for information purposes and are not included In the totals.
D. Name & Address of Borrower.
Michael S. Pirrtsr 50540 Cypress Print La Quints CA 92253
E. Name & Address of Seller. F. Name & Address of Lender.
Household Finance Corporation Of California 931 Corporate CASH
Center Udve Pomona CA 91769
G. Property Location:
53235 Avenida Villa
LA QUINTA CA 92253.0000
H. Settlement Agent 1. Settlement Date:
Integrsted Tide, Inc. 09113!2011
700 N Brand Blvd Suite 840 Glendale CA 91203
Place of Settlement D'Is Zonnent Date:
00N Brand Blvd SL 840 Glendale, CA 91203 0911312011.
.7..,
401. Contract sales price
101. Contract sales price 111,550.00
102. Personal property
402. Personal property
103. Settlemerd ctlarges to borrower (fine 1400) 975.00
403.
104.
404.
105.
405.
Adjustment for Items paid by seller In advance
Adjustment for Items paid by seller In advance
106. City/town taxes
406. City/town taxes
107. County taxes
407. County taxes
108. Assessments
408. Assessments
109. $100 Seller Per Diem 09/132011 to Close
409. $100 Seller Per Diem 09/1312011 to Gose
110.
410.
111.
411.
120. Gross Amount Due From Borrower 112,525.00
201. Deposit or earnest money 3,300.00
420. Gross Amount Due To Seller
501. Excess deposit (see instructions)
202. Principal amount of new loans)
502. Settlement charges to seller pine 1400)
203. Existing loan(s) taken subject to
503. Existing loan(a) taken subject to
204.
504. Payoff of first mortgage loan
205.
505. Payoff of second mortgage loan
206.
506.
207.
507.
208.
506.
209.
509•
Adjus6rentfor ifenm unpaid by seller
Adjustment for [terns unpaid by seller
210. Cityltown taxes
510. Citytown taxes
211. County taxes from 07/012011 to 09/132011 @ $1,251.90 507.62
per Semi -Annual t365 D
511. County.taxes from 07/012011 to 091132011®
$1,251.90 per Semi -Annual 365 Days)
212. Assessments
512. Assessments
213.
513.
214.
514.
215.
515,
216.
516.
220. Total Paid By/For, Borrower .3,807.62
301. Gross amourt due from borrower pine 120) 112,525.00
520. Total Reduction Amount Due Seller
601. Gross amount due to seller pine 420)
302. Less amounts palet by/for borrower pine 220) 3,807.62
602. Less reductions in amount due seller (fine 520)
303. Cash [X] From (] To Borrower 108,717.38
603. Cash ()C] To ( j From Seller
The Public Reporting Burden for this collection of Wontton is estimated at 35 minutes per response far collecting, re0mirg, and reporting the tlata. This
agency may not called this Information, and you ere not required to' complete this toren, unless it displays a currently valid OMB control number. No
confidentiality is asswed; this disclosure is mandatory. This Is designed to provide the parties to a RESPA covered transaction with Information during the
settlement Process.
NOTE Taxes have been prorated based on taxes for the year. Any re -proration will be handled between the buyer and seller. Ali nsifity bills (water, sewer,
_ electric, cable and maintenance fees) have been paid or well be paid or will be paid upon receipt of that bills.
WARNING: It Is a crime to known'mgly make false statements to the United States on this or any other similar form. Penafddes upon conviction can Include a
fit or Imprisonment For details see. Tide 18 U.S. Code Section 1001 and Section 1010.
' SUBSTITUTION FORM 1099 SELLER STATEMENT: The Information contained in Blocks E.G.H and I on rim 401(or If 401 Is asterisked, Ilm 403 and 404) Is
Important tax Information and is being furnished to the Internal Revenue Service. If you are requited to file a return, a negligence penalty or other sanction
will be Imposed on you if this Item is required to be reported and the IRS determines that M has not been reported
SELLER, you are required by law to provide the settlement agent with your torted taxpayer identification number. If you do not provide the settlement agent
with your;loom, rxt taxpayer Identification number. you may be subject to civil or criminal penalties imposed by law.
Under penalties of perjury, l tartly that the number sham on this statement is my coned taxpayer Identification number.
�f
Previous editions aro obsolete Pegs 1 of 3 HUD -1
i:� �� ,, I , . I 11•I �.,I i II i,� <i �l I'1�1- � .F� �y yl. ..r� I-,,�yNih t -
�l:'5ett(ententCharges. .�II '� ;�t i I :�i. �1�: il,' ^�< <t�l.:t I � (..�Ya«' '�' „! db :�,it. i., �'i•�
Divison of commission (line 700) as follows:
701. Listing Realtor Commission $2,231.00 To: Re/Max Real Estate
Consultants
702. Selling Realtor Commission $3,346.50 To: Windermere Real Estate
703. Commission paid at Settlement
7PR
704.
801. Our origination charge
(from GFE #1)
SEEM
802. Your credit or charge (points) for the specific interest rate chosen
(from GFE #2)
803. Your adjusted origination charge
(from GFE A)
804. Appraisal fee
(from GFE #3)
805. Credit report
(from GFE #3)
806. Tax service
(from GFE #3)
807. Flood certification
901. Dally interest charges
(from GFE #3)
(from GFE #10)
902. Mortgage insurance premium
(from GFE #3)
903. Homeowner's insurance
1001. Initial deposit for your escrow account
(from GFE #11)
(from GFE 419)
1002. Homeowner's insurance
1003. Mortgage insurance
1004. Property Taxes
1005.
1006.
1007. Aggregate Adjustment
1101. Title services and lender's title insurance To: Integrated Title, Inc.
(from GFE #4)
625.00
1102. Settlement or closing fee To: Integrated Title, Inc.
$500.00
1103. Owner's title insurance To: Integrated Title, Inc,
(from GFE #5)
1104. Lenders title insurance
1105. Lender's title policy limit
1106. Owner's title policy limit
$112,000.00
1107. Agents portion of the total insurance premium
1108. Underwriter's portion of the total title insurance premium
1109. Document Preparation To: ANAdeeds
$0.00
1110. Loan Tie In Fee
1111. Courier Fee To. Integrated Title, Inc.
1201. Government recording charges To: Integrated Title, Inc.
$125.00
(from GFE #7)
50.00
1202. Deed $50.00
1203. Transfer taxes To: Integrated Title, Inc.
(from GFE #8)
1204. City/County tax/stamps Deed $123.20 Mortgage $0.00 To: Integrated
Title Inc,
1205. State tax/stam
1301. Required services that you can shop for
(from GFE ins)
1302. Refundable Escrow Pad To: Integrated Title, Inc
300.00
1303. NHD Report Invoice #. PID2403167101 To: Property I.D.
1304. Water Bill Account Vs: 26519"87184 & 498719.687184 To: Coachella
VaI4, Water District
975.00
1 have Carefully reviewed the HUD -1 Settlement Statement and to the best of my ImoVedge and belief, it is a We and acanate statement of all receipts
and disbursemmRLYeetntmadets�s made on deAe )7n my account or by me In this transaction. I further cerfiy 1 that I have received a copy of HUD - Settlement Statement
rs�
Ilfxhael S. Pinter
Integrated Title, Inc. Date
Previous editions ate obsolete Page 2 of 3 HU41
D
i
TWT
4
P.O. Box 1504
i'mss• 7.M v ...,,: ;� _ ..
LA QUINTA; CALIFORNIA 92247-1504
OF 78-495 CALLS TAMPICO (760) 777-7000
LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7101
August 30, 2011 „
Michael Pinter
50540 Cypress Point
La Quinta, CA 92253
(760) 501-5674
RE: 53235 Avenida !Villa/ Parcel # 774-063-024/ Code Case #11-2500
1, Michael Pinter, am the prospective buyer of the property referenced above in the City of La Quinta. I
have been informed of the municipal code violations and the Notice of Substandard Building and/or
Property recorded against the property. Once I become the owner of the property, I will correct,the "
landscaping violations in the parkway by reviving the existing vegetation, removing the dead
vegetation and/or installing ground cover to the satisfaction of the City within thirty (30) days of the
close of escrow.
Additionally, I will provide -access to any concealed improvements for an inspection by the Building &
Safety Department for an evaluation. I will also submit approvable plans to the Building and Safety
Department for the two (2) new exterior doors that were installed without permit on the north and
south sides of the dwelling and agree to obtain an approved Final Inspection from the Building and
Safety Department within sixty (60) days from the close of escrow.
Sincerely,
Michael Pinter
0r-a(D
Print Name Signature Date.
F
.(Please include a photocopy of Government Issue identification when returning this letter or notarized
by a licensed notary.)
09!08/2011 10:06 8888087201• THE 4bELMO GROUP PAGE 01/02
C NTRACT {
MIKE INCE CONSTRUCTION MICHAEL PPNTFdt -
P.O.BOX 1801 53235 AVENIDA VILLA
LA QUINTA, CA. 92247. LA QUII`PTA, CA,
760-3334092 92253
CA.ST LIC. 0#754305
SCOPE OF WORD: DEMO STUCCO @ NORTH DOOR (FXIsnNG UNFINISHED REPAIR)
HAUL OFF WASTE
INSPF,CT ADDED FRAM [NG (INSURE IT IS UP TO CODE)
• REPAIR AS NECESSARY
INSPECT SILL @ SLAB (INSURE TT IS PRESSURE TREATED)
REPAIR AS NECESSARY
INSTALL INSULATING FOAM ONTO 2X4 FRAMING
LATH AND STAPLE OFF LATH
STUCCO REPAIRTO MATCH mC smr-
STUCCO MAIR @ sOUTI•I DOORWAY, (2" AROUND JAMB),
MATCH EXISTING SAND TEXTURE
NO COLOR ADDED (OWNER TO PAINT)
LABOR AND MATERIALS $400.00
CITY OF LA QUITTI'A PERMIT FEE (APPROMMATE) S50.00
TOTAL $450.00
APPROXIMATE START DATE ' 9.10 -II
APPROX]MATIE COMPLETION DATE 14-10-11 '
- NOTICE: FAUAJRE OF THE C ONI'RACI.OR WlrIMUT LAWFUL HXCUSE TO SUBSTAINTIALLY
COMMENCE woRK WITFIDI 20 DAYS FROM TM APPROX MATE DATE SPECIFIED IN THE
CONTRACT WHEN WORK WILL DWIN IS A VIOLATION OF THE CONTRACTORS LICENSE
LAW.
ANY CHANGES TO PERFORM EXTRA wOl&OR TO CHANGE WORK ARE TO BE MADE IN
WRITING
IN THE DORM OF A CHANGE ORDERIt CLEARLY DESCRIBING SCOPE OF WORK AND THE
COST, SIGNED DY THE CONTRACTOR AND TM OWNER OR ACTING AGENT.
LEIN RELEASES TO ACCOMPANY INVOICE SUBMISSION
RETENTION OF 10% OF TOTAL CONTRACT DUE AFTER COMPLETION OF WORK
ALL MA'TERL S AND WORK TO CONFORM TO THE UNIFORM BUILDING CODE
STANDARDS
DBPOSTT TO START
BILLS NG WILL BE DONE WEEKLY AND WILL NOT EXCEED WORK PERFORMED AND '
t 53235 Avenida Villa, �La
Scope of work to be„done
i A.: In response to work done with out permit (one single lite French
e` = door installed,3 0 In former 6-0 opening.'
` ,
a'. B.” Remove unfinished mortor coat to expose`framing, if framing isnot }
` i 16 inch on center, fix to make it that way, also`if floor plate is not
green pressure treated, then install one. Can either, take picture,for
}proof at this point or call for inspection.
i'
C. Install water proof barrier, caulk in seams where it,meets exsisting
stucco, install l/4 inch foam insulation (R-13 exsistirg in wall
-, u : ,';• ' 3 . already, take, picture for proof, install lath, call for inspection'if-
J necessary, or picture, apply 3 coat system , scratch, brown and,
. finish, also apply,I finish coat to masterbed set of doors,. as
requested by LQBD. Call for final. a:
' } ��,,, :r �* • � t t � c fes- �
F =.
D. - Work to -be done by licensed contractor, estimate is attached z
•* �,t ,l.� �. a ,. r , �' _. - 1. � .a - - ..
CA
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
lA iPt?RI'ANTt NOTICE TO PROPERTY 0WN1�Tt
Dear Property Owner.
An. application for a building permit has beenmatted in your name listing yourself as the builder of the property
improvements -specified at <3.23:5— 4-(te (' L= 62 Cid-
Vie are providing you with an Owner -Builder Acknowledgment and Information Veri€tcation 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 undeestanding 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.
i
ONS * S ACKNO-WLEl)GNWNT AND ')E KATION OF II OI ATION
Dl'RECHONS. Read and writial each statement below to signify you understand or verify tFis information.
M,1V 1. 1 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 ovm 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 myproperty.
OVV 1 I 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-.
�'t'}/�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.
1/y11Z4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
permits and contracts.
WY_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.
OTV 6. I understand if I am considered an "employer" under state and federal law, I oustregister 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.
rA 7. I understand under California Contractors' StateLicense Law, an Owner -Builder who builds single-family residentia
s6uctUres cannot -legally build them with the intent to offer them for sale, unless all work is performed by license(
subcontractors and the number of structures does not exceed four within any calendE.r year, or all of the work is performo
under contract with a licensed general building Contractor.
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. 6l ur es sustained by any subsequent owners) that result from any latent., construction defects in the .
workmanship or materials.
9. 1, understand I' may obtain more: information regarding my obligations as an "employer" from the Internat Revenue
Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California
Division of Industrial Accidents. .1 also understand I may contact the California Contractors' State License Board (CS -LB) at 1-
800-321-CSLB (2752) or www.csPa.ca.gov for more information about licensed contractors.
�10. 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 finat�cially ryponsle for proposed construction activity at the following address:
l 1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all
p1-6 Id laws and requirements that govern Owner -Builders as well as employers.
/ 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I
have provided on this form Licensed contractors are regulated by laws designed to protect the public. If you contract with
someone who does not have a license, 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 film is injured while wortang
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 Cofactors 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 isst�,.the.permic Note: A copy of the properly owner's driver's,Reeme, form nota amilan; or
other verification acceptable to the agency is required to be presented when the permit is issued to verify the property
owner's signature. A _
Signature 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 Perron(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: Date: