BWFE2017-0105eP
78-495 CALLE TAMPICO +0 Ct 0 D "`- Quiaz
VOICE (760) 777-7125
LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT
FAX (760) 777-7011
ONS (760) 777-7153
BUILDING PERMIT
. LICENSED CONTRACTOR'S DECLARATION
1 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 ($500).:
(06 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.).
co' 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.).
A_Z;'1'am exempt under Sec. . B.&P.C. for this reason
CDate:x- CP2 7 Ow
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
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1 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' r: _ Policy Number: _
I certify that in the performance of the work for which this permit is issued, l
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 3700 of the Labor Code, I shall forthwith
comply with those provisions.
Dat`e_: Z ApplicanC—
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,tor upon the above-
mentioned property for inspection purposes. /
Batt ` / % Signature -(Applicant -or -Agent)
Date: 6/2/2017
Application Number:
BWFE2017-0105
Owner:
z
Property Address:
53405 AVENIDA MARTINEZ
ANGELA MERAZ
LLJc
APN:
774091020
79330 SIERRA VISTA
Application Description:
MERAZ / 80 LF RETAINING BLOCK WALL
LA QUINTA, CA 92253
��yy
Property Zoning:
o
Application Valuation:
$5,000.00
cv _�5 W
fi
Applicant:CD
Contractor:
Z J
ANGELA MERAZ
OWNER BUILDER
79330 SIERRA VISTA
v Q
LA QUINTA, CA 92253
C!i
Llc. No.:
W
. LICENSED CONTRACTOR'S DECLARATION
1 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 ($500).:
(06 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.).
co' 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.).
A_Z;'1'am exempt under Sec. . B.&P.C. for this reason
CDate:x- CP2 7 Ow
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
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1 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' r: _ Policy Number: _
I certify that in the performance of the work for which this permit is issued, l
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 3700 of the Labor Code, I shall forthwith
comply with those provisions.
Dat`e_: Z ApplicanC—
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,tor upon the above-
mentioned property for inspection purposes. /
Batt ` / % Signature -(Applicant -or -Agent)
` Date: 6/2/2017
Application Number: BWFE2017-0105 Owner:
Property Address: 53405 AVENIDA MARTINEZ ANGELA MERAZ
APN: 774091020 79330 SIERRA VISTA
Application.Description: MERAZ/ 80 LF RETAINING BLOCK WALL LA QUINTA, CA 92253
Property Zoning:
Application Valuation: $5,000.00
Applicant: Contractor:
ANGELA MERAZ OWNER BUILDER
79330 SIERRA VISTA
LA QUINTA, CA 92253
Llc. No.:
--------------------------------------------------------------------------------------------
Detail: 80LF OF 6' GARDEN W/2'6" RETAINING WALL INSIDE SOUTH PROPERTY LINE [ANGELUS SPECIFICATION 5-1.51-Q] PRECISION CONCRETE BLOCK
SHALL BE COVERED WITH STUCCO, PAINT, OR TEXTURED COATING.WHERE VISIBLE FROM OUTSIDE THE PROPERTY. THE AREA BETWEEN THE BACK OF
CURB AND ANY FENCING SHALL BE LANDSCAPED, HAVE A SUITABLE PERMANENT IRRIGATION SYSTEM, AND BE CONTINUOUSLY MAINTAINED BY THE
PROPERTY OWNER. 2016 CALIFORNIA BUILDING CODES.
0
Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00
FINANCIAL
DESCRIPTION
ACCOUNT CITY
AMOUNT
WALL/FENCE - FIRST 100 LF
101-0000-42404 0i
$50.67
DESCRIPTION
ACCOUNT• CITY
AMOUNT
WALL/FENCE - FIRST 100 LF PC
101-0000-42600 0
$63.33
Total Paid -for BLOCK WALL:. $114.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
BSAS SB1473 FEE
101-0000-20306
0
$1.00
Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00
DESCRIPTION
ACCOUNT
CITY
AMOUNT
TECHNOLOGY ENHANCEMENT FEE
502-000043611
0
$5.00
Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00
Bin # t'
»
City of La Quinta
Building 8L Safety Division
78-495 Calle Tampico
La Quinta, CA. 92253 - (760) 777-7012
-Building Permit-Application and Tracking Sheet
Permit #
Project Address: '5 3 - q D5 Av•dk . M w4ine z
Owner's Name:
A. P. Number:
Address: q 330. Si erra di d
Legal Description:
City, ST, Zip: LA. lgv1h4-Ach g 3aS3
�
NG '
Telephone:Contractof 7 LO D- 2 Z I ,Z Z S g
Address: �\
Project Description:
City, ST, Zip: .
Telephone:
State Lic. City Lic.
&Oc, k wail on
An LF
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone:
P one:
Constructi
on Type: e: Occupancy:cu an
cY� ,
to
Ste Lic #:
Project ew Add
type (circle one 'nAlter Repair Demo
Name of Contact Person: an eid / t (k/ A-L
Sq. FL: 0L�
# Stories:
# Units:
Telephone # of Contact Person: 7 Lq D - ds') - az S
Estimated Value of Project: 5 DDD .
- APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Recd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance .
Tine 24 Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2"' Review; ready for correctionsfissue
Electrical
Subcontactor. List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A: Approval
Plans resubmitted
Grading
INHOUSE:-
'"' 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
BLOCK CO., INC.
Since 1946
ANGELUS BLOCK MASONRY FENCE WALL SYSTEM .
DESIGN CRITERIA:
1. DESIGN CRITERIA PER 2016 CBC
2. ALLOWABLE SOIL BEARING PRESSURE = 1500psf
3. ALLOWABLE SOIL PASSIVE PRESSURE = 150pcf
4. COEFFICIENT OF FRICTION = 0.25, COHESION = Opsf
5. CANTILEVER ACTIVE = 30pcf
6. MASONRY COMPRESSIVE STRENGTH, I m = 1500psi. SPECIAL -INSPECTION
NOT REQUIRED PER CBC SECTION 1704.2, EXCEPTION 2, 'U' OCCUPANCY.
7. USER TO VERIFY APPLICABILITY OF THE DEFINED DESIGN CRITERIA FOR THE
PROJECT SPECIFIC SITE.
NOTES:
1. REINFORCING STEEL SHALL BE DEFORMED AND CONFORM TO 'ASTM A615
GRADE 60. PROVIDE SPLICES'(LAPS) OF 48 BAR DIAMETERS OR 24
INCHES, WHICHEVER IS GREATER. CENTER VERTICAL BARS IN CELLS.
2. JOINT REINFORCEMENT ("LADDER" TYPE) SHALL BE COLD—DRAWN STEEL
WIRE CONFORMING TO ASTM A951. PROVIDE MINIMUM 6 INCH LAP SPLICES.
3.STRENGTH OF CONCRETE FOR FOOTINGS = 2500psi 0 28 DAYS, UNLESS
OTHERWISE REQUIRED BY SOILS REPORT.
4. CONCRETE MASONRY UNITS SHALL CONFORM TO ASTM C90. ANGELUS
BLOCK PRECISION, SPLIT FACE, BURNISHED, OR SHOTBLAST, WITH OR
WITHOUT MORTARLESS HEAD JOINTS (TONGUE—AND—GROOVE), OR
ANGELUS BLOCK SLUMPSTONE SHALL BE USED.
5. MORTAR SHALL BE SPEC MIX TYPE S PREBLENDED MASONRY MORTAR AS
MANUFACTURED BY E—Z MIX INC., CONFORMING TO PROPORTIONS AND
REQUIREMENTS OF ASTM C270, OR SPEC -MIX IWR MASONRY MORTAR AS
MANUFACTURED BY E—Z MIX INC., CONFORMING TO PROPERTY
REQUIREMENTS OF ASTM C270.
6. GROUT SHALL CONFORM TO ASTM C476, WITH AN 8-11 INCH SLUMP,
AND SHALL HAVE A MINIMUM COMPRESSIVE STRENGTH AT 28 DAYS OF
2000psi.
7. FIRST COURSE MAY BE WET—SET 1 1/2 INCHES MAX. WHILE CONCRETE'
IS PLASTIC.
8. CONCRETE BLOCKSHALL BE LAID IN RUNNING BOND PATTERN WITH
VERTICAL CONTINUITY OF THE CELLS.
9. VERTICAL CONTROL JOINTS SHALL BE SPACED AT A MAXIMUM OF
40'-0"o.c. OR 20'-0"o.c. IF WALL IS TO BE STUCCO COATED.OR
MORTAR WASHED
0. GROUT ALL CELLS WITH REINFORCEMENT.
1. INSPECTIONS: A. AFTER FOOTING IS READY FOR CONCRETE AND ALL
FOOTING REINFORCING IS TIED IN PLACE. B. AFTER VERTICAL
REINFORCEMENT IS IN PLACE AND CELLS ARE READY FOR GROUT.
2. FOR TYPICAL FOOTING STEP AND DRAINAGE BLOCK—OUT DETAILS
SEE DETAIL SHEET S-5.1.
3. DO NOT PLACE FOOTING WITHIN 5'-0" OF A SLOPE
GHL INC.
-p 228 East Badillo Street I Covina. CA 91723
t
T- 626.938.1595
626.938.0485
', 31 t w w.yh1ije.co•:t
6' High .Wall 2' to 4' Retaining
Toe -out Footing
C ® 110mph (ult.)
Risk Category I
678" Wide CMU
OPTIONAL WALL CAP
LADDER TYPE
MASONRY FENCE RETAINING WALL SCHEDULE
H,
'
'X' BARS 'Y BARS
16' LONG CMU 16" LONC CMU
S' MIN.
C' MIN.
2'-0"
4032"o.c.
4048"o.c.
2'-4"
0'-3'
AT FENCE
H' + 12"
6-
" WI(NOM.) CMU
6 I
2'-8"
4032"o.c.
4048"o.c.
2'-4"
0'-6-
'-6"3'-4"
SCHEDULE 0 CTR.
FOUNDATION
OF WALL. GROUT
3'— 4"
1 #4032"o.c.
#4048"o.c. 1
2'-6"
0'-9"
O
X
I
4'-0"
4032"o.c.
4048"o.c.
2'-10"
f V-2"
GHL INC.
-p 228 East Badillo Street I Covina. CA 91723
t
T- 626.938.1595
626.938.0485
', 31 t w w.yh1ije.co•:t
6' High .Wall 2' to 4' Retaining
Toe -out Footing
C ® 110mph (ult.)
Risk Category I
678" Wide CMU
OPTIONAL WALL CAP
LADDER TYPE
(#STD.
5 STD FOR SLUMPSTONE)
JOINT REINF. AT TOP COURSE,
4/
AT FIRST COURSE, AND 24"o.c.
AT FENCE
H' + 12"
6-
" WI(NOM.) CMU
6 I
DISTANCE TO EDGE OF
BARS PER
NEAREST ADJACENT
SCHEDULE 0 CTR.
FOUNDATION
OF WALL. GROUT
CELLS w/ REINF.
O
X
I
<
#4 HORIZ. 024"o.c.
0 RETAINING
,
OPTIONAL CHAMFER
4"0 SDR 35 PERF. PIPE W/
BACKFILL—
tc.f. 3/4" GRAVEL WRAPPED IN
WELL GRADED, CLEAN
MIRAFI 140N FILTER FABRIC—
SANDS OR GRAVEL OR
SLOPE TO DRAIN. WATERPROOF
COMBINATION
BACKSIDE OF RETAINING WALL
USC= GW,GP OR SW,SP
8" WIDE (NOM.) CMU
FULLY GROUTED
24" OUTSIDE FACE
X' BARS PER
OF BLOCK TO
OF VERT
o
SCHEDULE, LAP
=
24" MIN.LX
cWzi
N
F.G.
W
a
WET—SET FIRST
COURSE
#4 CONT. ---
C',
#4 CONT. 0 12"o.c.
CONT. CONC. FTG.
3^ CLR v
CONC. KEY
T.p
12" 1 12"
B' MIN.
LOADING PER SCHEDULE
1. SEISMIC, 5% DAMPING 0 1 SECOND
ACCELERATION Cs=0.33Wt.
2. FOUNDATION SIZES BASED ON
MAXIMUM WIND OR SEISMIC
LOADING.
CITY OF LA QUIN ?A
BUILDING & SAFETY DEPT
:APPROVED.
FOR CONSTRUCTION
DATE, 1BY .. —.-
#4016"o.c. STAGGERED
w/ STEM BAR FOR
TYPE 'A' WALLS
RETAINING 3'-4" & 4'-0"
,?,OF ESS/O
�
�G11
NO` 85681
�c EXP. 9-30-18 *
�9r C / v
F OF C A�\F
DATE SIGNED 4-12717
S-1.5LQ
#1.6-077
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.t NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit hambeen submitted in your name listing yourself as the builder of the property
improvements specified at - q3-105 .Ayakicit- / 7"hnn_
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
pDIRECTIONS: Read and initial each statement below to signer you understand or verify this information.
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.
_WV-* 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.
W^ 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.
_bh 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.
1\1 ` 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 contribute to unemployment
compensation for each "employee." I also understand my failure to abide by these laws may subject me to.serious financial .
risk.
V'_ 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.'
-P-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.
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.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:
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 govern Owner -Builders as.well as employers.
ttN 12. 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 onlyremedy 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. / h
Signature of property owner d Date: a f 7
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
Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above
information and certify its accuracy.. Note: A copy of the.owner's driver's license, form notarization,. or other verification
acceptable to the agency is required to be presented when the permit is issued to verify the property owners signature.
Property Owner's Signature: Date: