BRES2016-0260f
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78-495 CALLE TAMPICO Ct 0 D �NM�Cl/
LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT
BUILDING PERMIT
Application Number: BRES2016-0260
Property Address: 77541 LOS ARBOLES .
APN: 658260044
Application Description: ERIC MOSSMAN / ADDITION REMODEL
Property Zoning:
Application Valuation: $2,500.00
Applicant:
ERIC MOSSMAN
2025 W BALBOA BLV NO B
NEWPORT BEACH, CA 92253
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter9
(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
S, j 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.a did not build or improve for the purpose of sale.).
J?51, 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.).
/yI am exempt under Sec. . B.&P.C. for this -reason
l 0Wv
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
Lender's Address:
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 5/11/2017 ✓
Owner:
ERIC MOSSMAN
2025 W BALBOA BLV NO B
NEWPORT BEACH, CA 92253
Contractor: •
OWNER BUILDER
Lic. 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:
Carr' Polity Number: _
�' _I certify that in the performance of the work for which this permit is issued, I
S all not employ any person in any manner so as to become subject to the workers'
compensation laws of California, and agree that, if I should become subject to the
workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with those provisions.
Date: 1 + 1 Applicair i'
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 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-
mentioned property for inspection purposes.
D�at�e:— —`" f 1-1-7 Signature (Applicant or Agent):
r R
Date: 5/11/2017
Application Number: BRES2016-0260.
Owner:
Property Address: ' 77541 LOS ARBOLES
ERIC MOSSMAN
APN: 658260044
2025 W BALBOA BLV NO B
Application Description: ERIC MOSSMAN / ADDITION REMODEL
NEWPORT BEACH, CA 92253
Property Zoning:
Application Valuation: $2,500.00
Applicant:
Contractor:
ERIC MOSSMAN
OWNER BUILDER
2025 W BALBOA BLV NO B
NEWPORT BEACH, CA 92253
Llc. No.:
Detail: 6 SOFT BATHROOM ADDITION WITH SHOWER CONVERSION.'-THIS PERMIT DOES NOT INCLUDEELECTRICAL OR MECHANICAL WORK. ALL WORK
SHALL CONFORM TO THE 2013 CODE..
FINANCIAL •• •
DESCRIPTION ACCOUNT QTY. AMOUNT
ADDITION, FIRST 100 SF 101-0000-42400 0 $120.83
DESCRIPTION ACCOUNT QTY _ AMOUNT
ADDITION, FIRST 100 SF PC 101-0000-42600 0 $171.14
Total Paid for ADDITION: $291.97
DESCRIPTION
ACCOUNT
QTY
AMOUNT
BSAS SB1473 FEE
101-0000-20306
0
$1.00
Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
FIXTURE/TRAP
101-0000-42401
0
$12.09
DESCRIPTION
ACCOUNTQTY
AMOUNT
FIXTURE/TRAP PC
101-0000-42600
0
$12.09
DESCRIPTION
ACCOUNT
QTY
AMOUNT
WATER SYSTEM INST/ALT/REP
101-0000-42401
0
$12.09
DESCRIPTION
ACCOUNT
QTY
AMOUNT
WATER SYSTEM INST/ALT/REP PC
101-0000-42600
0
$12.09
Total Paid for PLUMBING FEES: $48.36
DESCRIPTION.
ACCOUNT
QTY
AMOUNT
REMODEL, FIRST 100 SF
101-0000-42400
0
$49.31
DESCRIPTION
ACCOUNT
QTY
AMOUNT
REMODEL, FIRST 500 SF PC _
101-0000-42600
0
$134.88
Total Paid for REMODEL: $184.19
DESCRIPTION
ACCOUNT -
QTY
AMOUNT
SMI - RESIDENTIAL
101-0000-20308
0
$0.50
Total Paid for STRONG MOTION INSTRUMENTATION SMI: $0.50
I U I ALY. :�SZb.UZ
Titf * 4 4 a"
P.D. Box 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
f
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 buildig perimit hasbee submitte m your name listing yourself as the builder of the property
improvements specified at ` r -S i-% .1 L—V-,b in
L155
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: .
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
DIRECTIONS: Read and initial each statement below to signs you understand or verify this information.
JO1 1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder"
building permit that erroneous) lies that the roe . er
3' �P property rty 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.
a( %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.
��. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I ma protect
yself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of
omy
wn.
�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.
6. I understand if I am considered an "employer" under state and federal law, I must register with the state and federal
overnment, 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
risk. may subject me to.serious financial
o
_(2111'7. 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. a
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 constriuction defects in the
workmanship or materials.
9.. 1 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.
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 legally, and financially responsible for proposed construction activity at the following address:
1 -7— L U l ( lre Ae0 1-2 - viii
I-- ' 11. 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 me'll as employers.
C�V12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I
have provided on this form Licensed contractors are regulated by laws designed to protect the public. If you contract with
someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss
you may sustain as a result of a complaint. Your only remedy against.unlicensed Contractors may be in civil court. It is also
important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working
on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and. wish to hire Contractors,
you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers'
compensation insurance coverage.
Before a building permit can be issued, this form must be completedaand 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 own Date:
5-11_�Y
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 ACTON 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
Permif 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:,4 copy of the -owner's driver's license, form notarization, or other verification
acceptable to the agency is required to be presented whe _ e permit is issued to verify the property owners signature.
Property Owner's Signatur : Date:
� CITY OF LA �{LQUINTA� SUB -CONTRACTOR LIST
7 e�
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PERMIT NUMBERV�" -6*- OWNERS �'1� - ��5�� -BUILDER
JOB ADDRESS . _
on the with the Building Inspection Card at all times in a conspict,ous- �l) ace. Only persons appearing on this list or their employees are authorized to work
This form shall be posted job
this Any 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 the voidance,
on job. changes
of building permit. For each. applicable trade; all information requested below must be completed by opplicant.. "On File" is not an acceptable response
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>: Wog keis Corii �ensatioit_I s a o
Sta-tc,.Contractor s Llcensc 1 ...... .
. r.-►dc>..;Classlficat�ort, _
Exp. Date License Number Exp. Date
Company Name Classification License Number Exp. Date Carrier Name �(For
(e.g. A, B, C-8)*` (xxxxxx) (xx/xx/xx) (e.g_ State Fund, CalComp) `(xx/xx/xx) (xxxx) (xx/xx/xx)
E�RThf1NORK
CbN RETE (C )I.
FfiAMING (C 5)
STRUCT STEEL (C 51)
}
;MASONRY
PLUMBING (C 36)
'LATH-.PLnSTER tC X51
-
.DRYWALL (C 9)
./
HVAC
1EL OTRICAL (C 10)
ROOFING (CJ)
z>
_
;SHEET N(ETA L (C 43)
FLOORING (C
GLAZINi `IC
:}INSUI_)ATIOI� (C 2)
SENVAGc DISE' (C X1.2)
PRINTING
,CAB INETS '(C'Q. '.
LAN US