BRES2017-0033 Permit & Plan78-495 CALLE TAMPICO
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LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT
BUILDING PERMIT
Application Number: BRES2017-0033
Property Address: 45545 DEERBROOK CIR
APN: 1 604404017
Application Description: GLOWKA/ BATHROOM REMODEL
Property Zoning:
Application Valuation: $45,000.00
Applicant:
WILBUR GLOWKA
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
I as owner of tFie property, or my employees with wages as their sole
We mpensation, 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
Mn
she did not build or improve for the purpose of sale.).
as owner of the property, am exclusively contracting with licensed contractors
struct 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
ntractors' State License Law.).
am exempt under Sec. B.&P.C. for this reason
Owner:
t/
CONSTRUCTIO E DING AGENCY 1
I hereby affirm under penalty of perjury at there is a construction lending agency for
the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's
Lender's Address:
I
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 Sectior 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 insvance carrier and policy number are:
Ca;1_nte
Policy Number:
I certify that in the performan•:e of the work for which this permit is issued, I
mploy any person in any mann=r 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 71t�
those provisions.
D ��� Applicant.
WARNING: FAILURE TO SECURE WORKER" C01' fENSATI�ONCOVERAGEISU�NLAWFUL�,
AND SHALL SUBJECT AN EMPLOYER TO CFiMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF
COMPENSATION, DAMAGES AS PROVIDE[ FOR IN SECTION 3706 OF THE LABOR CODE,
INTEREST, AND ATTORNEY'S FEES.
APPLICANT ACENOWLEDGEMENT
IMPORTANT: Application is hereby made to the Building Official for a permit subject to
the conditions and restrictions set forth or this application.
1. Each person upon whose behalf this application is made, each person at whose
request and for whose benefit work is perllormed 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 harmlessthe City of La Quinta, its officers, agents, and
employees for any act or omission related =o 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 an J state that the above information is correct.
I agree to comply with all city and county crdinances and state laws relating to building
construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
Dae:-+ / /'� Signature (Applicant or Agenf;, `�/ `_
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
017
Owner:
LU
WILBURAND ELIZABETH GLOWKA Q
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Contractor:
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OWNER BUILDER
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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 Sectior 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 insvance carrier and policy number are:
Ca;1_nte
Policy Number:
I certify that in the performan•:e of the work for which this permit is issued, I
mploy any person in any mann=r 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 71t�
those provisions.
D ��� Applicant.
WARNING: FAILURE TO SECURE WORKER" C01' fENSATI�ONCOVERAGEISU�NLAWFUL�,
AND SHALL SUBJECT AN EMPLOYER TO CFiMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF
COMPENSATION, DAMAGES AS PROVIDE[ FOR IN SECTION 3706 OF THE LABOR CODE,
INTEREST, AND ATTORNEY'S FEES.
APPLICANT ACENOWLEDGEMENT
IMPORTANT: Application is hereby made to the Building Official for a permit subject to
the conditions and restrictions set forth or this application.
1. Each person upon whose behalf this application is made, each person at whose
request and for whose benefit work is perllormed 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 harmlessthe City of La Quinta, its officers, agents, and
employees for any act or omission related =o 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 an J state that the above information is correct.
I agree to comply with all city and county crdinances and state laws relating to building
construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
Dae:-+ / /'� Signature (Applicant or Agenf;, `�/ `_
Date: 4/21/2017
Application Number:
BRES2017-0033
Owner:
Property Address:
45545 DEERBROOK CIR
WILBUR AND ELIZABETH GLOWKA
APN:
604404017
Property Zoning:
Application Valuation:
$45,000.00
Applicant:
Contractor:
WILBUR GLOWKA
OWNER BUILDER
---------------------------------------------------------------------------------------------
Llc. No.:
Detail: 133 SQ.FT. REMODEL
OF TWO BATHROOMS AND A CLOSET ADDITION, INCLUDING
RELOCATION OF PLUMBING FOR BATHROOM FIXTURES AND
INSTALLATION OF UPGRADED LIGHTING. THIS PERMIT DOES NOT INCLUDE POOL,
SPA, BLOCK WALLS OR DRIVEWAY APPROACH. 2016 CALIFORNIA
BUILDING CODES.
FINANCIAL
DESCRIPTION ACCOUNT QTY AMOUNT
BSAS SB1473 FEE
101-0000-20306 0 $2.00
Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $2.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
DEVICES, FIRST 20
101-0000-42403
0
$25.33
DESCRIPTION
ACCOUNT
QTY
AMOUNT
DEVICES, FIRST 20 PC
101-0000-42600
0
$25.33
DESCRIPTION
ACCOUNT
QTY
AMOUNT
DEVICES/FIXTURES, ADDITIONAL
101-0000-42403
0
$12.65
DESCRIPTION
ACCOUNT
QTY
AMOUNT
DEVICES/FIXTURES, ADDITIONAL PC
101-0000-42600
0
$3.15
Total Paid for ELECTRICAL: $66.46
DESCRIPTION
ACCOUNT
QTY
AMOUNT
FIXTURE/TRAP
101-0000-42401
0
$88.69
DESCRIPTION
ACCOUNT
QTY
AMOUNT
FIXTURE/TRAP PC
101-0000-42600
0
$88.69
Total Paid for PLUMBING FEES: $177.38
DESCRIPTION
ACCOUNT
QTY
AMOUNT
REMODEL, EA ADDITIONAL 500 SF
101-0000-42400
0
$22.80
DESCRIPTION
ACCOUNT
QTY
, AMOUNT
REMODEL, EA ADDITIONAL 500 SF PC
101-0000-42600
0
$18.24
DESCRIPTION
ACCOUNT
QTY
AMOUNT
REMODEL, FIRST 100 SF
101-0000-42400
0
$51.68
DESCRIPTION
ACCOUNT
QTY
AMOUNT
REMODEL, FIRST 500 SF PC
101-0000-42600
0
$141.36
Total Paid for REMODEL: $234.08
DESCRIPTION
ACCOUNT
QTY
AMOUNT
SMI - RESIDENTIAL
101-0000-20308
0
$5.85
Total Paid for STRONG MOTION INSTRUMENTATION SMI: $5.85
DESCRIPTION
ACCOUNT
QTY
AMOUNT
TECHNOLOGY ENHANCEMENT FEE
502-0000-43611
0
$5.00
Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00
Bin # ICity of La Quirts
Guifding &r Safety Division
Permit # 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-701,2
I -r- uilding Permit Application and Trackin€ Sheet
\
1073 ect Address: .eGrk7 COO- (-'4 r Owner-,`3Ljame��
A. P. Number:
Address:.
Legal Description:
C-ity'+ST; Zip, �� 5
r� .
n ra
o f c t r.
t C o �itlEi2�
T'1 h ne:�.
ee o
P /
Address:
Project"Description: em0 � U
� .
City, ST, Zip:
Telephone:
State Lic. # :
City Lic. #.:
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone:hone:
K.ProJStato
an
trueti Occupancy:
on Type: e:
Co s cY
Lic,.
ect type (circle one): New Add -,'n Repair Demo.
dame of:Contact"Person_^ ����DW N�
ILS q Ft.:, �.��
#Stories: %
# Units: i
STeleplione # ofContact-Person: �: 3e?-fD'
-gEstimated: Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rcc'd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Cales.
Reviewed, ready for corrections
Plan Chec-- Deposit
Truss Cafes.
Called Contact Person
Plan ChecL Balance.
Title 24 Calcs.
Plans picked up
Constructdn
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2°" Review, ready for corrections/issue
Electrical .
SubcontactorList
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
II.O.A. Approval
flans resubmitted
Grading
IN Ii OUSE:-
Review, ready for corrections/issue
Developer [impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees,
Total Permit Fees
Tdf 4 41 a"
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 been submitted inyourame listing yourselfas 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 un&rstanding of each provision,
signed, and returned this form to us at our official address indicated. An agent of the ovaier cannot execute this notice
unless you, the property owner, obtain the prior approval of the permitting authority:
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
DNECTIONS: Read and initial each statement below to si i you understand or verify this information.
J 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. 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.
V/ 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.
y 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.
l
�S. I understand if I employ or otherwise engage any persons, other than California licensed C :)ntractors, and the total value
of my construction is at least five hundred dollars ($500), including labor and materials, I may _-)e considered an ".employer"
under state and federal law.
V 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 :ontribute to unemployment
compensation for each "employee." I also understand my failure to abide by these laws may suI ect me to.serious financial
risk..
/ 7. I understand under California Contractors' State License Law, an Owner -Builder who bu'lds single-family g armly 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 E.11 of the work is performed
under contract with a licensed general building Contractor.
✓. 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.
—Z-9. 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.tslb.ca.gov for more information about licensed contractors.
_V_/10. I am aware of and consent to an Owner -Builder building permit applied for,in my name, and understand that I am the.
party le ally , and financially responsible for proposed construction activity at the following address:
5�� AEt� k Cat , JA 44a 573
/ 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I wills abide by all
applicable laws and requirements that govern Owner -Builders as mell as employers.
V/ 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the infomiation I
have provided on this form Licensed contractors are regulated by laws designed to protect the public. If you contract with
someone who does not have a license, the .Contractors' State License Board may be unable to assist you with any financial loss
you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also
important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working
on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and. wish to hire Contractors,
you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers'
compensation insurance coverage.
Before a building permit can be issued, this form must be completed and signed by the property owner and returned to
the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form 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.
/L e-
Signature of property owner f-' Date:
Note: The following Authorization Form is required lobe 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 thepermit is issued to verify the property owner's signature.
Property Owner's Signature: Date:
a Building Permit Number. LCS— 3j
Project Description: Renovation/Improverient
-
Exempt 0 ;
(Materials may contain hazardous imstes and
are not subject to recycling provisionsj
OF
Construction Construction Debris Management Plan
Plan Submittal Data
4/8/2017
Job sue Address
45545 Deerbrook Circle
owner's Name
Bill & Liz Glowke
Number, street, or PO Box
45545 Deerbrook Circle
coy, state, Postal Code
La Quints, CA. 92253
Owner's Phone Number
.
Owner's EAW Address
_ Project Mansge_rs Name
Project Managers phone Number
Project Managers E-mail Address
+ . Builder / Contrector
- - Number, Sbeet or PO Box
Cpy, State; Postal Code
a
Project square Footage
l City Approval By
R
Date of City Approval
To B_ a Discarded;
Product
Trash
Asphalt
Brick/Block '
Cardboard
Commingled
Concrete
Drywall
Donated / Reuse•
*Describe items
Liz Glowka
. •
•
OwnedBlll & Liz Glowke
45545 Deerbrook Circle
La Quints, CA. 92253
1,500 square feet
R.enado Goukllock-DEC/Buntec An—
kaI.
lob 1I�
Tons
1.50 Not recyclable
0.00 Recyclable
0.00 Recyclable
0.00 Recyclable
0.00 Recyclable
0.00 Recyclable
0.80 Recyclable
0.00 Recyclable
f
RECEIVED
--- ---APR-10-201 ...___....
CITY OF LA QUINTA
COMMUNITY DEVELOPMENT
-_Product
Tons
Masonry (broken)
01
Plaster
0.17
Scrap Metal
01
Tiie (floor)
0.2
Tile (roof)
0.0
Wood- 1
1.7
Landscape Debris 1
0.0
Totals:' Recvcle Trash Projected Diversion:
2.8 1.5 B6.12%
I understand it is the property owners responsibility to submit copies of weight tickets or receipts to the District
Environmental Coordinator as these hauls occur. I hereby certify that completion, Implementation and adherence of the
Debris Management Plan (DMP) for the above named project shell guarantee that at least 65% of the jobsite waste is
diverted from landfilling. The remaining material will be recycled or reused. l will divert, for recycling or re -use, remaining
materials generated from the first day of the project through the completion of the project In accordance with this plan. This
DMP is Issued in the name of the property owner(s) and shall remain their property throughout the construction and/or
demolition project. A contractor serving as agent of the owner may obtain a DMP for the owner. However, the DMP is still
Issued in the name of the property owner(s) and the owner retains legal responsibility for ensuring that the provisions of the
DMP are adhered to. The property owners) and general contractor shall be kept informed of the diversion progress through
bi-monthly reports. If self -hauling, all refuse material from this project site must be taken to an approved recycler or transfer
Owner / Developer / Project Manager / Superintendant Date
I
[O (J
Conttrualtion -Debris Maniapment Plaft
Summary Of Requirements;;
As of January 1, 2017, The Green Building Standards Code (CALGmen) requIres that the construction
of most now structures In the State of California comply with sections 4.408 and 5.408 Of the code In
..accordance.Wth-Assembiy-Bfll.939,requidrlg'ihMnomari3.,than,55%ofjobatte-waste,tie-disposed-ofas.
trash at local land fill sites and transfer stations. Exceptions may be'made for certain projects under
certain conditions.
The City of La Quints Is committed to the highest level of environmental respect.'tO c6h68rvIng'Our
Precious natural resources *and setting an example to provide for a better world for generations to
come. Recycling helps keep reusable resources out of larWflils and will also reduce disposal costs.
I.MPORTANT-.Burrtec Waste & Recycling Services is the City's franchise
hauldr.1f you choose to self -haul any recyclables or trash, ybu must
provide copies of all weight tickets andlor�receipts from the transfer
station, -landfill, or recycler -as the job progresses. Clean-up companies
and other haulers are not permitted to haul waste or recyclables from the
City of La QuintA.,Self-haul weight tickets "should be submitted to:
Renado Go'uldldbk, District Environmental Coordinator -
'rgouldlock@buhtecdesert.com, or fixed to (760) 340-0417, or mailed to:
41575 Eclectic Street, Palm Desert, CA. 92260.
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