12-1211 (RER)4 P.O. BOX 1504 �VOICE 760
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: 10/11/12
Application Number: 12-00001211 Owner: D
Property Address: 52545 AVENIDA VILLA DEREK SCOTT
APN: 773-303-026-1 -000000- 54350 AVENIDA HERRERA
Application description: REMODEL - RESIDENTIAL LA QUINTA. CA 92253 OCTProperty Zoning: COVE RESIDENTIAL it 12012
Application valuation: 520
crTYofLAQuuurA
Contractor: Plk'ANOE bEpT
Applicant: Architect or Engineer: Owner
-------------------------------=----------------------------------------------------------=------
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).:
(*) 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.).
1 _ 1 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.).
( 1 I am exempt under Sec. , BAP.C. for this reason
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the
work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name:
Lender's Address:
LQPERMIT
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
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
700 of the Labor Code, I shall forth w' ncomply wit tho A provisions.
tte�: Z scant: FAILU TO SECURE WORKERS' MPENSATION 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 building construction, a "ereby authorize representatives
;te::
hi o ty enter up��/on the above-mentioned property for i ep 'on pu oses.le
Iffitature (Applicant or Agent):17 X
Application Number . . . . . 12-00001211
Permit BUILDING PERMIT
Additional desc . .
Permit Fee . . . . 17.00 Plan Check Fee 11.05
Issue Date . . . . Valuation . . . . 520
Expiration Date . . 4/09/13
Qty Unit Charge Per Extension
BASE FEE 15.00
1.00 2.0000 HND BLDG 501-2,000 2.00
-------------------------------7--------------------------------------------
Special Notes and Comments
REPLACE (4) WINDOWS & REPLACING (2)
SLIDING GLASS DOORS WITH FRENCH DOORS.
2010 CODES.
----------------------------------------------------------------------------
Other Fees . . . . . . . . . BLDG STDS ADMIN (SB1473) 1.00
ENERGY REVIEW FEE 1.11
STRONG MOTION (SMI) - RES .50
Fee summary Charged
Permit Fee Total 17.00
Plan Check Total 11.05
Other Fee Total 2.61
Grand Total 30.66
LQPERMIT
Paid Credited Due
.00 .00 17.00
.00 .00 11.05
.00 .00 2.61
.00 .00 30.66
• , . Bin. # i11
�f Ld
tY Q nta
Building 8l; Safety Division
Permit # P.O. Box 1504,78-495 Calle Tampico
La .Quinta, CA 92253 -:(760) 777-7012
Building Permit -Application and Tracking Sheet
Project Address: JA Owner's Name:
i A. P. Number. Address: U e
Legal Description: City, ST, Zip:
i Contactor.pM Telephone: �s ?ri '41'
Address: Project Description: a
City, ST, Zip: 1Z.
Telephone:
State Lie. # : City Lic. #;
Arch , F.ngr., Designer
Address:
City., ST, Zip:
Telephone:. Construction Type- Occupancy:
State Lic. #: Project type (circle one): New Add'n Alter Repair Demo
Name of Contact Person: Sq. Ft.: # Stories: # units:
':.
Telephone # of Contact Person: Estimated Value of Project Zd
`
APPLICANT: DO NOT WRITE BELOW THIS LINE
# SabmIttal Req'd Recd TRACKING PERMIT FEES
Plan Sets Plan Check submitted Item Amount
Structural Coles
Reviewed, ready for corrections
Plan Check Deposit.
1lttss Gales.
Called Contact Person
Plan Check Balance -
Title 24 Cates.
Plans picked up
Construction -
—
Flood-.Plansresubmitted
- -
----i-• -
'- ---
--- —
.— -
-Mechanical— ------ ___-__.
Grading plan
V Review, ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.L
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
3" Reviewi ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.LP.P.
Pub. Wks. Appr '
Date of permit issue
School Fees
Total Permit Fees
Prescriptive Certificate of Compliance: Residential CF 1R ALT
Residential Alterations age 1 of
Project Name: Climate Zone N N of Stories
5,41 5 a4,q
General Information
Site Address: Enforcement Agency Date:
Building Type O Single Family O Multi Family Circle the Front Orientation: N. E. S, W, or degrees
Conditioned Floor Area (CFA): Project Type: O Alterations O Envelope O Fenestration O Roof O HVAC
Replacement or Chan2e Out O Duct Replacement O Water Heater
7A'S form is not to be used for NewIY Constructed Buildings or Additions
Insulation Values For Opaque Surfaces (for Furring use the Mass and Furring Strips Constntelion table below)
Assembly Alteration
O Opening of framed cavity alone - Alterations that involve the opening of the framed cavity of a wall, ceiling. or floor must install the
mmrdatory minitnun insulation value per f 150 far the altered assembly. Fill in Columns A -C and enter mandatory insulation value to Column H.
O Replacement of cadre auembly - Replacement of an entire wall, ceiling, or floor assembly requires the installation of Component
PoclaP!_ D in.!yle"On N-JWF in Tc: 1e 151-C- Fall in C.-1,:.>.,,. s - t
Opaque Surface DCURS For the furred portiosed of Mau Walls we Fards& Strips Conmrrcties Table below.
A B C D E F G I H I 1 I J
Pro Standard Values From JA4 Table
Framing Tess. Framed Continuous JA4 Proposed
Ta� Assembly Name Material Spacing, U- JA4 Table Cavity Inudatiion Assembly Ass, b,
iD or T and Size' or Other' factor` Numbers R -value` R -Value Cell Values U -factor
Note: Forfurnd assensblles, accowsting for Conrimioas / m R -value, see P JAI -3 and F Conor sow table below. a� bion 4-1. For calcadamq frred waW rue the Mass and
I. For TaelD indicate the idem antion name that matches rhe building plant.
2. Indicate the Assembly Name or type: RoofICeiling, Walls, om,ease the Frame type ardSiu: For
Wood Metal, Metal Buildings, Mass, enter 2x4, 2x6, or etc... see JAI for other possible frame type assemblies.
3. Enter the thicaw-is for mass in inches or Spacing between framing members enter; 16 "or 24 "OC: or Other for all other assembly description
such as Concrete Sandwich Panel. SpandSel Panel, Logs. Straw Bale Panel and etc....
4. Based on the Climate Zone; enter the Standard U factor from Table 151-8. C or D for each different assembly Name or type.
S. Enter the Table number that closely resembles the proposed assembly.
6. Enter the R -value that is being installed in the wall cavity or between the framing; otherwise, enter
7. Enter the Continuous Insulation R-valuue for the proposed assembly; otherwise, enter "0"
8. Enter the row and column of the U factor value based on Column F Table Number and enter the Assembly U factor in Column J
9. The Proposed Assembly U factor, Column J. must be eoual m nr to« ,t.,,., .u.. r r _.__ :- --- r — ____.-.
Furring Stri s Construction Table for Mass Walls Oral
A B I C I D
Proposed Properties of Masonry and Concrete
E
F C H I J K
L M
Added
Interior
or Exterior Insulation
Walls From Reference
in Furring Space from Reference
Joint AppEadix Table 4.3-5 4.3.6 4.3.7
b
G
Joint APPCBdii
Tabk 43.13
w
—
V
to
Mau
Assembly
Ta
t
T
t- $ >^
Final
Assembi
Thicknes
Numbct'
< >
U -factor • Comment
Registration Number: Registration Date.Time: HERS Provider: _
2008 Residential Compliance Forms August 2009
'Prescriptive Certificate of Compliance: Residential CF -IR -ALT
Residential Alterations age 2 of
Project Name: Climate Zone # # of Stories
Mass and Furnng Strips Construction(footnotes)
1. indicate the type ofassembly to include; Hollow Unit Masonry Walls, Solid Unit Masonry, Solid Concrete Walls, Etc. Additional assemblies can
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
-6. The Final Assembly is calculated using Equation 4-2 or Equation 4-40ithe Reference Joint Appendix JA4. Tire equation is the inverse of Col
added to Column I. Column K is the inverse from column J.
7. Insert the calculated Ufbctor value on to the Onaoue Surface netaite 1n 1'nlv�nn _t
FENESTRATION PROPOSED AREAS
M R �P!acirvg winda•:v alone — Rep acrirent zrinG ws sisal! meet the U -Factor and SHGC Value requirements of Component Package D in
Table l Sl -C. The Total Fenestration and West facing Area requirements are not applicable.
[3 Adding 50ft or less of window area —Newly installed windows shall meet the U-Factorand SHGC Value requirements of Component
Package D in Table 151-C.
® Adding more than 50ft2 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
Fenestration Type and Frame (North, East,
indow, Glass Door or S I t South,West)
1'ropsedAma'
Maximum Maximum
-factorz• 3 SHGCz'•'
NFRC or Default
Values
�ACt
A
B
C
D
E
F
G
CFA of
Allowed
Existing
Allowed
1. Fenestration area is the area of total glazed product ae. glass plus frame). Exception: When a door is less than 50•/ glass, the fenestration
area may be the glass area plus a 'T 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 specied on the CF -1 R ALT Form.
4. Submit a completed WS -31? Form if a reduced SHGC is calculated with exterior shading.
5.1 applicable at this stage enter "NFRC" for NFRC Certified windows or are CEC "Default " values found in Table 116-A or B.
ALTERED FENESTRATION
ALLOWED AREAS
(Co tete if more than 50ft' of fenestration is added)
A
B
C
D
E
F
G
CFA of
Allowed
Existing
Allowed
Entire
%of
Fenestration
Area
Fenestration
Area
Proposed Areal. 4
Dwelling
CFA"
Area'
RemovedArea
Addedb
A x B
D + C -
Total Fenestration
Areaz ft
West Fenestration Area
(Required In
CZ's 2,4&7-15
1. The Proposed West Fenestration Area includes West -sloping skylight area and any other skylight area with a pitch less than 1:12.
2. Enter 20.0 when no West orientation restriction or 15% when West fenestration is being installed in Climate Zones 2, 4, & 7-15. Note that the
maximum allowed fenestration can only be 5% of the CFA as indicated in Column F. Column G must be equal to or less than Column F.
3. In climate zones 2, 4, 7-15, no more than 5% of the CFA is allowed for west facing glazing.
4. Existing Fenestration area must be counted toward the maximum allowed 15% or 20•/ of the whole building and calculated in Column G. The
Proposed Area must be less than or equal to Column F.
5. Enter the fenestration removed as part of the alteration if any in column A
6. Enter the Fenestration area that is being added as part of the alteration.
2008 Residential Compliance Forms March 2010
General Information
Site Address:
Enforcement Agency Date:
Building Type ❑ Single Family ❑ Multi Family
Circle the Front Orientation: N, E, S, W, or degrees
Conditioned Floor Area (CFA):Project
Type: O Alftrations O Envelope O Fenestration O Roof O HVAC
Proposed Properties
R laccmem or C e Out O Duct Re [acement O Water Heater
: lbls or m Is Not to be used or New01 COnstruded
Bulld1W or Addltlons
Insulation Values For Opaque Surfaces (for Furring use the Mass and Furring Strips Construction table below)
Assembly Alteration
O Opening of framed cavity alone - Alterations that involve the opening of the framed cavity of a wall, ceiling, or floor mutt install the
mardotory minimum insulation value per §150 for the altered assembly. Fill in Columns A -C and enter mandatory in ukttion valse in Column H.
O Replacement of entire assembly - Replacement of an entire wall, ceiling, or floor assembly requires the installation of Component
f2±Oge- n trawl-" vIgms in Tc6le 151-C Fill in Co- &-a -.s A - J.
O a ue Snr[ace Details For the furred ed of Mass Walb see Furrial Strip Coastrucdoe Tabk belvw.
A B C I D E F G I H I I I J
Pro Standard Values From JA4 Table
Tai/
ID
Assembly Name
or Type'
Framing Thickness, Framed Continuous JA4 Proposed
Material Spacing, U- JA4 Table Cavity Insulation Assembly Asxrnbl�
and Size, or Other' factor' Numbers R -value R -Value I Cell Valuer U -factor
L M
Proposed Properties
of Masonry and Concrete
Added Interior or Exterior Insulation
Walls From Reference
in Furring Space from Reference
Note: For firmed assemblies, accorrrtireg for Cmdnww lnndarm R
F Conwucrion sable below. -vnhre, see Page JAI -3 and Equation I- 1. For oa/ertatarg fused walla we the At= and
_
1. For Tag/ID indicate the identicanon mune that matches the building plans.
2. Indicate the Assembly Nome or type: RoofiCeiling, Walls, _.. dote the Frame type and Size: For
Wood Metal, Metal Buildings, Mass, enter 2x1, 2x6, or etc... see JAI for other possible frame type assemblies.
3. Enter the thic mess for mass in inches or Spacing between framing members enter: 16 "or 24 -0C. or Other for all other assembly description
such as Concrete Sandwich Panel, Spanrb+el Pawl, Logs, Straw Bale Panel and etc....
I. Based on the Climate Zone: enter the Stardand U fang from Table 151-B, C or D for each dierent assembly Name or type.
5. Enter the Table number that closely resembles the proposed assembly.
6. Enter the R -value that is being installed in the wall cavity or between the framing: otherwise, enter "0 ".
7. Enter the Continuous Insulation R -value for the proposed assembly; otherwise, enter -0 ".
8. Enter the row and column of the U factor value based on Column F Table Number and enter the Assembly U factor in Column J
9. The Proposed Assembly U factor, Column J. must be equal to or less than the Standard 11 -factor in Column E to earra/v.
Fumng Strips Construction Table for Mass Walls Only
A I
B I C I D I
E
F
I G H I I J I
K
L M
Proposed Properties
of Masonry and Concrete
Added Interior or Exterior Insulation
Walls From Reference
in Furring Space from Reference
Joint AD
ndi: Table 4.3.5 4.3.6 43.7
Joint AppeadixTable43.0
Mass
Aswmbty
Name or JA4 Table
-
a S
>
y
Final
Assembly
Thickness'
T ' Number' < >
e 'Q, R
$
' < >
U -fader' Comment
Registration Number: Registration Date.Time:
2008 Residential Compliance Forms
HERS Provider:
August 2009
Prescriptive Certificate of Compliance: Residential CF -IR -ALT
Residential Alterations
age 5 of
Project Name:
Climate Zone #
# of Stories
HERS VERIFICATION SUNWARY 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 beforefinal
inspection
Duct Sealing & Testing HERS verification is required for this measure.
E3 YES ❑ 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)IDii and the newly installed ducts are to be insulated per §151(f)10.
EXCEPTION: Existing duct systems that are extended, which are constructed, Insulated or sealed with asbestos.
13YES ONO YES: In Climate Zones 2 and 9-16, if the existing space -conditioning system (HVAC equipment and ducting) is replaced, the
duds are to be sealed per § 152(b) I Di.
13YES 13NO 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, 000ling or heating coil, or the furnace heat exchanger) the duds are to be
sealW per §152(b)IE.
Q 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.
Q EXCEPTION: Duct systems with less than 40 linear feet in unconditioned space.
EXCEPTION: Existing duct systems constructed insulated or sealed with asbestos.
Refrigerant Charge- Split System HERS verification is required for this measure.
0 YES 13 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 (CF1) Ventilation System and Fan Watt Draw
The ventilation requirements of § I 50(o) do not apply to existing residential homes.
Ducted Split Systems -Air Conditioners and Heat Pumps: Airflow HERS verification is required for this measure.
0 YES 0 NO YES: in Climate Zones 10 through 15, when the existing space -conditioning system (HVAC equipment and ducting) is
repl the airflow and fan watt draw shall be verified per § 152 1 Ci to meet the requirements of § 151 7B.
Documentation Author's Declaration Statement
• I certify that this Certificate of Compliance documentation is accurate and complete-,
NanrfL 1_
►`�
Si
Company:
Date:
Address:
?J
If Applicable EA or CEPE
Yc.(
(Certification #):
City/State/Lip:�� � � •Phone:
19
Responsible Building Designer's Declaration Statement
• I 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.
• I 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 1 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 rmit application.
Name:
Signature:
Company:
Date:
Address:
License:
City/State/Zip:
Phone:
For assistance or questions regarding the Energy Standards, contact- the Energy Hotline at. 1-800-772-3300.
2008 Residential Compliance Forms March 2010
PROPERTY AT 52545 VILLA, LA QUINTA; CA
KITCHEN
1
1
I
------------I
LIV. RM
1
ITEM
OUD & NEW su DESCRIPTION Uf
SHGC
1
8o4o, oxo
WINDOW
.34
.35
2
3o3o, ox
WINDOW
.34
.35
3
6068
FR. DOOR
.18
.34
4
6068
FR. DOOR
.18
.34
5
4o5o, ox
WINDOW
.34
.35
5
4o5o, ox
WINDOW
.34
.35
3
B.R.
DIN. RM. 1 1
1 I B.R. 5
L -------I
1
I
GARAGE
B.R. 116
NORTH
THE ABOVE LISTED EXIXTING WINDOWS OR DOORS ARE REPLACED WITH NEW.
THE SIZES ARE UNCHANGED. THE NEW HAVE U -FACTOR AND SOLAR HEAT GAIN
PROPERTIES AS SHOWN IN THE TABLE.
P_O_ Box 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
PROPERTY OWNER'S PACKAGE
(7 60) 77 7 -70 12
FAX (760) 777-7011
Disclosures & Forms for Owner-Bullders Applying for Construction Permits
LWOIt'!.NOTICE TQ PROPERTY OWNER
Dear Property Owner.
An application for a building permit has been 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 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.
OWWRR'S AC4QWT.EDGMENT AND VERIFICA'T'ION OF INFORMATION
DIREC77ONS: Read and initial each statement below to signify you understand or verify this information.
�I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder'
mg permit that erroneously implies that the property owner is providing his or her own labor and material personally_ 1, 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
construction and are not hiring a licensed Contractor to assume this responsibility.
3. I understand as an "Owner -Builder" I am the responsible
.Y'�party of record on the permit [understand that l 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.
3t. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
permits and contracts.
1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value
:0 my construction is at least five hundred dollars ($500), including labor and materials, 1 may be considered an "employer"
under state and federal law. y
6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and federal
go eritment, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment
compensation for each "employee." 1 also understand my failure to abide by these laws may subject me to serious financial
risk.
II 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential
trtictures 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.
1 understand as an Owner -Builder if I sell the property for v%-Wch this permit is issued, 1 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.
understand I may obtain more information regarding my obligations as an "employer' from the Internal Revenue
Service, the United States Small Business Administration, the CaliforniaDepartment of Benefit Payments, and the California
Division of Industrial Accidents. 1 also understand 1 may contact (tic California Contractors' State License Board (CSLB) at 1-
800-321-CSLB (2752) or www.cslb.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 l am the
party legally and financially responsible for proposed construction activity at the following address:
agree that, as the Party legally and fmancWly responsible for this proposed construction activity, I will abide by all
applicable laws and requirements that govern Owner -Builders as well as employers.
agree to notify the issuer of this form inunediately of any additions, deletions, or changes to any of the information
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 ruay 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 undcistand 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 property 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
(lie agency responsible for issuing the permit, Note: A copy of the property owner's driver's license, form notarizati»n; or
other verification acceptable to the agency is required to be presented when the permit is issued to verify the property
owner's signature.
i
Signature of property owner _ '� �. r j / %
Datc:� c
Note: The following Authorization Forret is required lobe completed by the property owner only when designating
an agent of the property owner to apply for a constntction permit for the Owner -Builder.
Aui,uoRt _A"PION OF AGEN"f TO ACTON PROPERTY OWNER'S BEIM F
Excluding the Notice to Property Owner, the execution of which 1 understand is my personal responsibility, t 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 e
C,
Name of Authori 1i DR!UFI<LICEN4C _ ...------
Address of Authl
ti .:,s C
s S:,OTT =tiG NONE
I declare under p e DEREK RICHARD we and (personally filled out the above
information and54350 AVENIDA HERERRA
LA OUINTA, CA 92253 notarization, or other verif cation
acceptable to the'' �c,e t 117 ;;,�� the property owner's signature.
NONE .'
Property Owner 'Y���j� - a. t 1251gg8
M
` 6%02" .�01 BLU
��noiaoo,s�ep asrni� •�
07/0812011