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BRES2015-044179230 DESERT STREAM DR LA QUINTA, CA 92253 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 theF_ basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for al— permit subjects the applicant to a civil penalty of not more than five hundred dollars ($5001.: C) 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 hre did not build or improve for the purpose of sale.). C( 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 tntractors' State License Law.). ( am exempt under Sec. B.&P.C. for this reason 1' Date I ✓ oC 3I Owne� : 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: Llc. No.: WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier* Policy Number: _ c'e'rtify that in the performance of the work for which this permit is issued, I shall Zot _employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Date:� o b Applicant: WARNING: FAILURE TO SECURE WORKERS' COMPENS N COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. APPLICANT ACKNOWLEDGEMENT IMPORTANT: Application is hereby made to the Building Official for a permit subject to the conditions and restrictions set forth on this application. 1. Each person upon whose behalf this application is made, each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this application , the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and employees for any act or omission related to the work being performed under or following issuance of this permit. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above-meptiony property for inspection purpos Date_ Signature (Applicant or Agent): 44 C� O�i VOICE (760) 777-7125 78-495 CALLE TAMPICO a D FAX (760) 777-7011 LA QUINTA, CALIFORNIA 92253 COMMUNITY DEVELOPMENT DEPARTMENT INSPECTIONS (760) 777-7153 BUILDING PERMIT Date: 1/19/2016 Application Number: BRES2015-0441 Owner: Property Address: 79230 DESERT STREAM DR WILLIAM FOLDEN APN: 604341011 Application Description: NGUYEN / CONVERT ONE STALL OF GARAGE INTO A BEDROOM AND BATH 92253 Property Zoning: i ro ►-.. i t Application Valuation: $7,000.00 Z C 1) 1=' AI Applicant: Contractor: 7J HUONG NGUYEN OWNER 79230 DESERT STREAM DR LA QUINTA, CA 92253 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 theF_ basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for al— permit subjects the applicant to a civil penalty of not more than five hundred dollars ($5001.: C) 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 hre did not build or improve for the purpose of sale.). C( 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 tntractors' State License Law.). ( am exempt under Sec. B.&P.C. for this reason 1' Date I ✓ oC 3I Owne� : 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: Llc. No.: WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier* Policy Number: _ c'e'rtify that in the performance of the work for which this permit is issued, I shall Zot _employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Date:� o b Applicant: WARNING: FAILURE TO SECURE WORKERS' COMPENS N COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. APPLICANT ACKNOWLEDGEMENT IMPORTANT: Application is hereby made to the Building Official for a permit subject to the conditions and restrictions set forth on this application. 1. Each person upon whose behalf this application is made, each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this application , the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and employees for any act or omission related to the work being performed under or following issuance of this permit. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above-meptiony property for inspection purpos Date_ Signature (Applicant or Agent): DESCRIPTION FINANCIAL INFORMATION ACCOUNT QTY AMOUNT PAID 'PAID DATE BSAS SB1473 FEE 101-0000-20306 0 $1.00 $0.00 PAID BY METHOD RECEIPT # CHECK # CLTD BY Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00 $0.00 DESCRIPTION ACCOUNT QTY AMOUNT . PAID PAID DATE RESIDENTIAL, FIRST 1,000SF 101-0000-42403 0. $145.03 $0.00 PAID BY METHOD RECEIPT # CHECK # CLTD BY DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE RESIDENTIAL, FIRST 1,000SF, PC 101-0000-42600 0 $47.86 $0.00 PAID BY METHOD RECEIPT # CHECK # CLTD BY Total Paid for ELECTRICAL - NEW CONSTRUCTION: $192.89 $0.00 DESCRIPTION ACCOUNT • QTY AMOUNT. PAID PAID DATE APPLIANCE REPAIR/ALTERATION 101-0000-42402 0 $12.09 $0.00 PAID BY METHOD RECEIPT # CHECK # CLTD BY DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE APPLIANCE REPAIR/ALTERATION PC 101-0000-42600 0 $4.83 $0.00 PAID BY. METHOD RECEIPT # -CHECK # CLTD BY DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE VENT FAN 101-0000-42402 0 $12.09 $0.00 PAID BY METHOD RECEIPT # CHECK # CLTD BY DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE VENT FAN PC 101-0000-42600 0 $4.83 $0.00 PAID BY METHOD RECEIPT # CHECK # CLTD BY Total Paid for MECHANICAL: $33.84 $0.00 DESCRIPTION ACCOUNT QTY AMOUNT : PAID PAID DATE FIXTURE/TRAP 101-0000-42401 0 $36.27 $0.00. PAID BY METHOD RECEIPT It CHECK # CLTD BY DESCRIPTION ACCOUNTQTY AMOUNT PAID PAID DATE FIXTURE/TRAP PC 101-0000-42600 0 $36.27 $0.00 PAID BY METHOD RECEIPT # CHECK # CLTD BY DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE WATER SYSTEM INST/ALT/REP 101-0000-42401 0 $12.09 $0.00 PAID BY METHOD RECEIPT # CHECK # CLTD BY DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE WATER SYSTEM INST/ALT/REP PC 101-0000-42600 0 $12.09 $0.00 PAID BY METHOD RECEIPT # CHECK # CLTD BY Total Paid for PLUMBING FEES: $96.72 $0.00 DESCRIPTION ACCOUNTQTY AMOUNT PAID PAID DATE REMODEL, EA ADDITIONAL 500 SF 101-0000-42400 0 $21.75 $0.00 PAID BY METHOD.: RECEIPT # : , CHECK # CLTD BY DESCRIPTION ACCOUNT ..• QTY AMOUNT. PAID PAID.DATE REMODEL, EA ADDITIONAL 500 SF PC 101-0000-42600 0 $17.40 $0.00 PAID BY METHOD RECEIPT # CHECK # CLTD BY DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE REMODEL, FIRST 100 SF 101-0000-42400 0 $49.31 $0.00 PAID BY METHOD RECEIPT # CHECK # CLTD BY DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE REMODEL, FIRST 500 SF PC 101-0000-42600 0 $134.88 $0.00 PAID BY METHOD RECEIPT # CHECK # CLTD.BY Total Paid for REMODEL: $223.34 $0.00 DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE SMI - RESIDENTIAL 101-0000-20308 0 $0.91 $0.00 PAID BY METHOD RECEIPT # CHECK # CLTD BY Total Paid for STRONG MOTION INSTRUMENTATION SMI: $0.91 $0.00 TOTALS:00 T. Permit Details PERMIT NUMBER City of La Quinta BRES201S, 0441 Description: NGUYEN / CONVERT ONE STALL OF GARAGE INTO A BEDROOM AND BATH Type: BUILDING, RESIDENTIAL Subtype: ADDITION Status: APPROVED Applied: 12/1/2015 SGU Approved: 1/15/2016 JJO Parcel No: 604341011 Site Address: 79230 DESERT STREAM DR LA QUINTA,CA 92253 Subdivision: TR 25363-2 Block: Lot: 4 Issued: Lot Sq Ft: 0 Building Sq Ft: 0 Zoning: Finaled: Valuation: $7,000.00 Occupancy Type: Construction Type: Expired: No. Buildings: 0 No. Stories: 0 No. Unites: 0 NOTES Details: CONVERT 3RD. CAR GARAGE TO BEDROOM. CONSTRUCTION IS PER 2013 CRC CODES MARY FASANO Printed: Tuesday, January 19, 2016 10:36:02 AM 1 of 3 C§? SYSTEMS ADDITIONAL CHRONOLOGY CHRONOLOGY TYPE STAFF NAME ACTION DATE COMPLETION DATE NOTES PLAN CHECK PICKED UP MARY FASANO 12/4/2015 12/4/2015 OWNER PICKED UP PLANS PLAN CHECK SUBMITTAL STEPHANIE GUMPERT 12/1/2015 12/1/2015 RECEIVED TELEPHONE CALL JIM JOHNSON 12/3/2015 12/4/2015 CALLED DUY NGUYEN TO INFORM HIM PLANS ARE READY FOR CORRECTIONS TELEPHONE CALL JIM JOHNSON 1/15/2016 1/15/2016 CALLED DUY TO INFORM HIM THE PLANS HAVE BEEN APPROVED CONDITIONS CONTACTS NAME TYPE NAME ADDRESSI CITY STATE ZIP PHONE FAX EMAIL APPLICANT HUONG NGUYEN 79230 DESERT STREAM LA QUINTA CA 92253 DR Printed: Tuesday, January 19, 2016 10:36:02 AM 1 of 3 C§? SYSTEMS >� ` Permit Details PERMIT NUMBER �City of La Quinta BREs201�5=044 CONTACTS NAME TYPE NAME ADDRESSI CITY STATE ZIP PHONE FAX EMAIL CONTRACTOR OWNER OWNER WILLIAM FOLDEN • 92253 FINANCIAL INFORMATION DESCRIPTION ACCOUNT CITY AMOUNT PAID PAID DATE ` RECEIPT # CHECK # METHOD PAID BY CLTD - BY . BSAS SB1473 FEE 101-0000-20306 0 $1.00 $0.00 Total Paid for BUILDING STANDARDS ADMINISTRATION - $1.00 $0.00 BSA: RESIDENTIAL, FIRST 101-0000-42403 0 $145.03 $0.00 1,OOOSF RESIDENTIAL, FIRST 101-0000-42600 0 $47.86 $0.00 1,000SF, PC Total Paid for ELECTRICAL - NEW CONSTRUCTION: $192.89 $0.00 APPLIANCE 101-0000-42402 0 $12.09 $0.00 REPAIR/ALTERATION APPLIANCE 101-0000-42600 0 $4.83 $0.00 REPAIR/ALTERATION PC VENT FAN 101-0000-42402 0 $12.09 $0.00 VENT FAN PC 101-0000-42600 0 $4.83 $0.00 Total Paid for MECHANICAL: $33.84 $0.00 FIXTURE/TRAP 101-0000-42401 0 $36.27 $0.00 FIXTURE/TRAP PC 101-0000-42600 0 $36.27 $0.00 WATER SYSTEM 101-0000-42401 0 $12.09 $0.00 INST/ALT/REP WATER SYSTEM . 101-0000-426000 $12.09 $0.00 INST/ALT/REP PC Total Paid for PLUMBING FEES: $96.72 $0.00 Printed: Tuesday, January 19, 2016 10:36:02 AM 2 of 3 S YS Tf MS .�4 Permit Details PERMIT NUMBER City of La Quinta BRES2015=04414 INSPECTIONS REVIEWS Attachment Type CREATED OWNER DESCRIPTION PATHNAME CLTD DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE RECEIPT # CHECK # METHOD PAID BY BY REMODEL, EA 101-0000-42400 0 $21.75 $0.00 1/15/2016_ APPROVED 0 0441.pdf ADDITIONAL 500 SF REMODEL, EA 101-0000-42600 0 $17.40 $0.00 ADDITIONAL 500 SF PC REMODEL, FIRST 100 SF 101-0000-42400 0 $49.31 $0.00 REMODEL, FIRST 500 SF 101-0000-42600 0 $134.88 $0.00 PC Total Paid for REMODEL: $223.34 $0.00 SMI - RESIDENTIAL 101-0000-20308 1 0 $0.91 $0.00 Total Paid for STRONG MOTION INSTRUMENTATION SMI: $0.91 $0.00 TOTALS.t $0.00 INSPECTIONS BOND INFORMATION REVIEWS Attachment Type CREATED OWNER DESCRIPTION PATHNAME REVIEW TYPE REVIEWER SENT DATE DUE DATE RETURNED DATE STATUS REMARKS NOTES 1ST BLDG NS (1 WK) JIM JOHNSON 12/1/2015 12/8/2015 12/3/2015 REVISIONS REQUIRED 2ND BLDG NS (1 JIM JOHNSON WK) 12/29/2015 2/5/2016 1/15/2016_ APPROVED 0 BOND INFORMATION Printed: Tuesday, January 19, 201610:36:02 AM 3 of 3 RSYS7EMS Attachment Type CREATED OWNER DESCRIPTION PATHNAME SUBDIR ETRAKIT ENABLED DOC 12/3/2015 JIM JOHNSON 79-230 DESERT 79-230 DESERT 0 STREAM.docx STREAM.docx DOC 12/3/2015 JIM JOHNSON SCHOOL FEES BRES2015- SCHOOL FEES BRES2015- 0 0441.pdf 0441.pdf Printed: Tuesday, January 19, 201610:36:02 AM 3 of 3 RSYS7EMS i Bin # Permit #{ '^ �� 1Z�h • roject Address: '1' y `'11` ` Qky of La Quin to Building u Safety Division ... . 78-495 Calle Tampico .. La Quinta, CA 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet S ! ' Owner's Name: A. P. Number:all Address: 'T 9 Legal Description: • ont'actor:ele —City, ST, Zip: v;rna 2-253 h p one: Mims= roject Description:o4f ity, ST, zip: -Telephone: tate Lic. # : Arch., Engr., Designer: City Lie. Address: City, ST, Zip: ele h Telephone: one: State Lic. #` ame of Contact Person: v Construction Type: 0 ccu anc Y• P pRepair Demo tYPa (circle one): New Add n Alter Nt S _ # Stories:#Units: ' elephone # of Contact Person: — — _ stimated Value of Project: APPLICANT: DO NOT WRITE•BELOW THIS LINE # Submittal Req'd Recd TRACKING 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 Cafes. Plans picked up, Construction Flood plain plan Plans resubmitted Mechanical Grading plan 2nd Review, ready for-corrections/issue Electrical Subcontactor List Called Contact Person Plumbing Grant Deed Plans picked up S.M.1. II.O.A. Approval Plans resubmitted Grading IN ROUSE:- '"! Review, ready for correctionstissue. Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub. Wks. APPr Date of permit issue School Fees, Total Permit Fees plu, CERTIFICATE: OF. COMPLIANCE _ .0%%fIED s Desert Sands Unified. School District ; 2ay cyo 47950-Dune Palms Road. "'E PAIS a . - - t INo" WELLS y La Qun.ita CA 92253- ° �y Date: 12/7/2015 ,o`"u°uiio "y�� No.: 15-00084-1. (760)771-8515 Owner: Huong Nguyen: Email; Address: 79230 Desert Stream Dr Jurisdiction: La Qui.nta . City: La Quinta Tract.#: Type: Residential Addition <.500 sq ft Lot # Street No. Street.Name Sq.'Feet APN Permit No. 79230' Desert.Streani Dr .210,- 604-341011 . RECEIVED. .JAN 192016• . CITY OF L4 AUINTA Comments: Exempt. COMMUNITY DEVELOPMENT At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patios/walkways, residential additions under 500 square feet, detached accessory structures•(spaces that do not contain facilities for"living, sleeping, cooking eating, or sanitation) or replacement mobile homes. It has been determined that the above-named owner is exempt from paying school fees at this time due to the following reason: Residential Addition 500 Sq Feet or Less. .. Exempt This certifies that school facility fess imposed pursuant to Education Code Section 17620-and Government Code 65995 Et Seq. in the amount of $0.00 X 210 S.F. or $0.00 have been paid.for'the property listed above and, that building" permits and/or Certificates of Occupancy for this, square. footage in the. proposed project may now be issued.. . Fees Paid By: _Exempt / Duy NguVerr - Check No.: Exempt Bank Name/Recipient of Certificate Telephone: Funding: Exempt By Dr. Gary Rutherford v Superintendent Fee Collected Exe to b * : Kell Jones / Y y Air3unt Due: + _$0.00 , l - 1r % Original Paym2''t s) Rec'a: .x0.00 I New Paym&nt Recd: 50:00-, Over/glnder: $0,_o NOTICE: Purs of to Gove ment Code Section 66020(d)(1), this will serve to notify you that -the 90-day approval period in which you may protest the fees or other paymer identified above will begin to run from the date: on which the building or, installation .permit for this project is issued; or from the .date on which those amounts are paid to the "District(s) or to another public,entity authorized to collect them on the District('s) behalf, whichever is earlier. , Notice to Building Department: THIS DOCUMENT.VALID ONLY IF IMPRINTED WITH EMBOSSED SEAL. II �F�a�rw .P.O. Box 1504 LA QUINTA; CALIFORNIA 92247-1504 BUILDING & SAFETY.DEPARTMENT 78-495 CALLE TAMPICO (760) 777-7012 LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7011 PROPERTY OWNER'S PACKAGE' Disclosures & Forms for Owner -Builders Applying for Construction Permits IMPORTANT! NOTICE TO PROPERTY OWNER Dear Property Owner: An application for a building permit has been sub ed in our name listin ourself as a builder of the ro erty improvements specified at 2f'� �QR -- W1 116 � �y Q _9, 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 pernmitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION DIRECTIONS: Read and initial each statement below to signer you understand or verify this information. 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.' _UL�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. j 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. 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: A_H6. 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 to serious financial risk. 7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential .structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. �H 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. AJ9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California 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. a10. 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 L an� "cially responsible for , proposed , construction activity+, r.>,il _aA e following address: ffiN11. 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 govem Owner -Builders as well as employers. 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information ve I haprovided 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 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. Signature of property owner Date: .4 L G 20 5 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 notdrization, 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: CITY OF 1A QUINTA S013-C0.NTR,ACT0Rr1IST '' JOB ADDRESS PERMIT NUMBER:' OWNER l - - ,; BUILDER ' This form shall be posted on the iob with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this list or their employees are authorized to work on this job. Any changes to this list must be-approved by the Building Division prior to commencement of work. -Failure to comply will result in a stoppage of work and/or thevoidance_ of buildingermit. -For each applicable trade, all information re uested below must be'com feted by applicant.' licant. "On File" is not an acceptable response-. P PP Q P P P - ...:.::.............. ..... Trade / Classification Contractor .: ctor.s.License........................ State Contra �...................................................W rkers Com .ensation.lns. .......e~............... :: ..................................:.o. P.. .............._.......... C�t ss. Y,..............._............................. e::>>;:: CompanyName License Number i Ex e Date • arrier Name Polis Number Exp' License Number' Exp. Date . . - �B 8 � e. . A C 9 xxxxxx - x x x x x / x ( / 1 Fund, CalCom ate F e. . St 1 ( P 9 a Varies) (Format F 1 x xxx. x / 1 x/ � xx xx ) x x xx xx/ / 1 E'A'RTHWO.......:L..........)........._. - i Ul'r _i Nap %Ml _ '��uw r U� .CONCRETE.{C. 8) •_ � - - � _ AMING F _ STRUCT STEEL..(C.51) i ' MASONRY (C 29):''%'>:;:?'' _ - PLUMBING (C 36) ...V. .... - - r ' .. :n�i:�iiii:'�i:�: �i:!v:� i..::. �:::.. i::, ..:iiiii:4:�.:;... LATH,::PLA$.TER {C 35) .L• t ' ` • ` . N - Y . a � C . _ , _ � ! - DRYWALL (C 9 - `Y - - s _ e,� _ '- • - _ - , 'ter - -- :.:. .... ...::::: HVAC :('C. 20) ,.;>:.;'.;.::. 1 • L r • r' _ a - � " ::ELECTRICAL (C :..:.:::. ?'F.:i i': iii, v:: ........ .... ROOFING �- � �♦ .r .. .. .. :SHEET.;METAL:(C.-43)...:: ;;:.: ,. •a r ;,. ,r r . , " FLGORING (C ..........;;::;;: • f x • L `o ` .'c Sp L"I a SEWAGrt DISP (C :: U wr :;PAINTING.{:C 33) Ip ` _ r- C,ERAMIC.TILE (C 54) s :.;. :.:.....:: CABINETS fG 6) <:'<' .. , { FENCING (C.13) - # + < ;LANDSCAPING r