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BWFE2015-0046
Bin #City of La Q uin to -Building$i: Safety Division P.O. Box 1504 78-495 Calle Tampico . Permit #� , // L �l La Quinta, CA 92253 - (760) 777-7012. Building Permit Application and Tracking Sheet Project Address: S3 `�� " t� vlfh Owner's Name: �4iV,-� 14e1c:AJ --- A. P. Number: 7 7 Ll-- i7 — ps .F O�p Address: 161 Legal Description: City, ST, Zip: -� All+� 17"le tq - q4v Contractor:. /k oAe ►S CoA)�r�uciav Telephone: ��� t< Address: Project Description: City, ST, Zip: Tele hone: 76o — — s::>..,3s•`:#s``?`.<::;,;::> i/ State Lic. # : %��j/�S " A G L City Lie. Arch., Engr., Designer:we Address:O g ig ,41f Z City, ST, Zip: SO • A(.�;1�� �'tt . �w/ . l Telephone:.<2z) :?//ti — -7-27 7? :3 est ? :- :: • ;•:;; ..;:::: "'``�`:: >< <%:Y:: > <`#`>'s" Construction Type:. Occupancy: State Lic. #: Dp,�.. -�� / '�C:iC .� S 7� Project type (circle one): New Add'n Al Repair Demo Name of Contact Person: -r&,A.)y Ae4�_O Sq. Ft.: #Stories: #Units: Telephone #,of Contact Person: lirl?e9 — -.N; .- 4(20 Z Estimated Value of Project: a wo -� APPLICANT: DO NOT WRITE BELOW THIS LINE #1 Submittal Req'd Rec'd TRACMG Ac. PERMIT FEES Plan Sets Plan Check submittedS Item Amount' Structural Calcs. Reviewed, ready for corrections 3 n Plan Check Deposit Truss Calcs.. Called Contact Person 3 ;7�p Plan Check Balance. 1 Title 24 Calcs. Plans picked up Construction ' Flood plain plan Plans resubmitted Mechanical Grading plan 2°" Review, ready for.eorreclio/issue z Electrical Subcontactor List Called Contact Person Plumbing Grant Deed Plans picked up S.M.I.' H.O.A. Approval Plans resubmitted Grading IN HOUSE: Rcvicw, ready for correctionsfissuc Developer Impact Fee Planning Approval' Called Contact Person x A.I.P.P: Pub. Wks. Appr Date of permit issue School Fees Total Permit Fccs. Ito 4 5 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) 7.77-7012 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 in your name listing yourself as the builder of the property improvements specified at We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by 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 signify you understand or verify this information: ,41 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 beheld 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 rimy 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. 3.'l understand as an "O.wner-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 bylaw 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-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. A-7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family le-famil 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. k8. 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.'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.. 110. 1 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. 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 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,..vr 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:w� 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, Ihereby 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 Perinitfor my project. Scope of Construction Project (or Description of Work):. Project Location or Address: Name of Authorized- Agent: Tel No Address of Authorized Agent: 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 io be presented when the pennit is issued to verify the property, owner's signature. . Property Owner's Signature: Dater < � � \ r. C < � � \ C ` M1 _ Y . _ 'r. ,., < � � \ C � M1 _ Y . _ , t GREGORY J. COOK R.C.E. Civil Engineering* Planning* Surveying CA * NV o AZ o OR o CO o ID o Hl JOB SHEET NO. 1 OF CALCULATED BY 6 ) c, CHECKED BY DATE DATE SCALE SS ...........................'.............s....... .............. ............. 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