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BRES2018-025478-495 CALLE TAMPICO Tit�p D _i- QK&M LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT BUILDING PERMIT Permit Type/Subtype: BUILDING RESIDENTIAL/REMODEL Application Number: BRES2018-0254 Property Address: 78002 LAGO DR APN: 658270034 Application Description: BOZEK / 284SF ADDITION WITH INTERIOR REMODEL TO KITCHEN Property Zoning: Application Valuation: $22,947.20 Applicant: RICHARD BOZEK 78002 LAGO DR SEP 13 2019 LA QUINTA, CA 92253 F ID CITY OF LA QUINTA DESIGN & DEVELOPMENT DEPARTMENT 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 s is the applicant to a civil penalty of not morethan five hundred dollars ($500).: (, as owner of the property, or my employees with wages as their sole 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 he aIe did not build or improve for the purpose of sale.). , 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.). (_) I am exempt under Sec. .&P for hi a n Date: 40 Owner 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: VOICE (760) 777-7125 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 9/13/2019 Owner: RICHARD BOZEK 78002 LAGO DR LA QUINTA, CA 92253 Contractor: OWNER BUILDER 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: Carr' r Policy Number: _ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become sub' ct to the orkers' compensation laws of California, and agre t ld In a subje the workers' compensation provisions c 5e i 70 the o ode, I sh 11 orthwith comply with those pro v' ions. Dat Applicant_ 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, NTEREST, 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 e a nformatio is correct. I agree to comply with all city and county ordinances nd a laws la g buildin construction, and hereby authorize representative f thi o en p the abov mentioned property or inspection purposes. Rat Signature (Applicant or e Date: J/13/2019 Application Number: Property Address: APN: Application Description Property Zoning: Application Valuation: Applicant: RICHARD BOZEK 78002 LAGO DR LA QUINTA, CA 92253 BRES2018-0254 78002 LAGO DR 658270034 BOZEK / 284SF ADDITION WITH INTERIOR REMODEL TO KITCHEN $22,947.20 Owner: RICHARD BOZEK 78002 LAGO DR LA QUINTA, CA 92253 Contractor: OWNER BUILDER Llc. No.: Detail: 284SF ADDITION AT ATRIUM WITH REMODEL TO KITCHEN [ENGINEERED] THIS PERMIT REDUCES THE AMOUNT OF COMPLIANT SLEEPING ROOMS TO ONE (1) AS EXTERIOR ESCAPE AND RESCUE OPENINGS HAVE BEEN REMOVED, AND REPLACES EXPIRED BUILDING PERMIT RER-13-1343 AND IS RESOLUTION TO CODE CASE CE-13-1699. 2016 CALIFORNIA BUILDING CODES. F, FINANCIAL INFORMATION DESCRIPTION ACCOUNT CITY AMOUNT ADDITION, EA ADDITIONAL 500 SF 101-0000-42400 0 $67.10 DESCRIPTION ACCOUNT CITY AMOUNT ADDITION, EA ADDITIONAL 500 SF PC 101-0000-42600 0 $18.72 DESCRIPTION ACCOUNT CITY AMOUNT ADDITION, FIRST 100 SF 101-0000-42400 0 $131.07 DESCRIPTION ACCOUNT CITY AMOUNT ADDITION, FIRST 100 SF PC 101-0000-42600 0 $184.13 Total Paid for ADDITION: $401.02 DESCRIPTION ACCOUNT CITY AMOUNT PLAN CHECK/PERMIT EXTENSION PROCESSING 101-0000-42600 0 $107.27 Total Pairs fnr AnRA11U1CTRAT1%1C- Ci n7 77 DESCRIPTION ACCOUNT QTY AMOUNT 101-0000-42600 ($104.05) DESCRIPTION ACCOUNT CITY AMOUNT 101-0000-42600 ($15.95) DESCRIPTION ACCOUNT CITY AMOUNT 101-0000-42600 ($109.05) DESCRIPTION ACCOUNT CITY AMOUNT HOURLY CHARGE - CITY BUILDING STAFF 101-0000-42600 2 $109.05 DESCRIPTION ACCOUNT CITY AMOUNT HOURLY CHARGE - CITY BUILDING STAFF 101-0000-42600 0 $210.95 DESCRIPTION ACCOUNT CITY AMOUNT HOURLY CHARGE - ESGIL STRUCTURAL ENGINEER 101-0000-42600 1 $104.05 DESCRIPTION ACCOUNT CITY AMOUNT HOURLY CHARGE - ESGIL STRUCTURAL ENGINEER 101-0000-42600 j 0 $15.95 Total Paid for BLDG CITY STAFF - PER HOUR: $210.95 DESCRIPTION ACCOUNT CITY AMOUNT BSAS SB1473 FEE 101-0000-20306 0 $1.00 Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00 DESCRIPTION ACCOUNT CITY AMOUNT Credit Card Fee 101-0000-43505 0 $2.25 Total Paid for Credit Card Fee: $2.25 DESCRIPTION ACCOUNT CITY AMOUNT RESIDENTIAL, FIRST 1,000SF 101-0000-42403 0 $156.04 DESCRIPTION ACCOUNT CITY AMOUNT RESIDENTIAL, FIRST 1,000SF, PC 101-0000-42600 0 $51.49 Total Paid for ELECTRICAL - NEW CONSTRUCTION: $207.53 DESCRIPTION ACCOUNT CITY AMOUNT APPLIANCE REPAIR/ALTERATION 101-0000-42402 0 $13.00 DESCRIPTION ` ACCOUNT I CITY 1 AMOUNT APPLIANCE REPAIR/ALTERATION PC 101-0000-42600 0 $5.20 Total Paid for MECHANICAL: $18.20 DESCRIPTION ACCOUNT CITY AMOUNT PARTITION 101-0000-42400 0 $78.02 DESCRIPTION ACCOUNT CITY AMOUNT PARTITION PC 101-0000-42600 0 $143.56 Total Paid for PARTITION: $221.58 DESCRIPTION ACCOUNT CITY AMOUNT PLAN CHECK DEPOSIT - ADDITION/REMODEL 101-0000-42600 1 $125.00 DESCRIPTION ACCOUNT CITY AMOUNT PLAN CHECK DEPOSIT - ADDITION/REMODEL 101-0000-42600 1 $104.55 Total Paid for PLAN CHECK DEPOSIT - ADDITION/REMODEL: $229.55 DESCRIPTION ACCOUNT CITY AMOUNT FIXTURE/TRAP 101-0000-42401 0 $13.00 DESCRIPTION ACCOUNT CITY AMOUNT FIXTURE/TRAP PC 101-0000-42600 0 $13.00 DESCRIPTION ACCOUNT CITY AMOUNT WATER SYSTEM INST/ALT/REP 101-0000-42401 0 $13.00 DESCRIPTION ACCOUNT CITY AMOUNT WATER SYSTEM INST/ALT/REP PC 101-0000-42600 0 $13.00 Total Paid for PLUMBING FEES: $52.00 DESCRIPTION ACCOUNT CITY AMOUNT 101-0000-42600 ($0.50) DESCRIPTION ACCOUNT CITY AMOUNT SMI - RESIDENTIAL 101-0000-20308 0 $0.50 Total Paid for STRONG MOTION INSTRUMENTATION SMI: $0.00 DESCRIPTION ACCOUNT CITY AMOUNT TECHNOLOGY ENHANCEMENT FEE 502-0000-43611 0 $5.00 Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00 �r !+ PERMIT # SAC5201J5 • 452.5 - �y PLAN LOCATION: �69 1 $65 Project Address: o �d Project Description: Pool, Remo 1, Add't, Elect, Plumb, Mech APN #: lN'c G�ritAIL iL'oDr- -to Applicant Name: AU4419415 Address: ?$ . otm LA -do 14L City, ST, Zip: Telephone: Email: Valuation of Project $ Contractor Name: New SFD Construction: Address: Conditioned Space SF City, St, Zip Garage SF Telephone: Patio/Porch SF Email: Fire Sprinklers SF State Lie: City Bus Lie: Arch/Eng Name: Construction Type: Occupancy: Address: Grading: City, St, Zip Telephone: Bedrooms: Stories: # Units: Email: State Lie: City Bus Lie: Property Owner's Name: New Commercial / Tenant Improvements: Address: Total Building SF City, ST, Zip Construction Type: Occupancy: Telephone: Email: 78495 CALLE TAMPICO LA QU I NTA, CA 92253 760-777-7000 • ' OFFICE USE ONLY Submitfal ' r �� Req'd Ree'd Plan Sets Structural Calcs Truss Calcs Title 24 Calcs Soils Report Grading Plan (PM10) Landscape Plan Subcontractor List Grant Deed HOA Approval School Fees Burrtec Debris Plan Planning approval Public Works approval Fire approval City Business License roe mans ement 51 iCr Desert Club Dr. Offsolt p p Y g La Quiutci. Ca.ltfotnia,9225; 1'60-%71-9546 office 760-771-1655 fax To whom this may concern, As of today, July 26, 2019, the property located at 78002 Lago Drive, La Quinta, Ca. 92253 is in compliance with the HDA Rules & Regulations and all Architectural Guidelines. There are no outstanding complaints or violations concerning this property. If you have any questions, please feel free to contact our office. Thank you, SummerAievander, C.M.C.A. Avail Property Management 5135o Desert Club Dr. # 4 La Quinta, CA 92253 760-771-9546 Phone 76o-T71-1655 Fax UTAN 5N 6 TUCKER, LLP February 21, 2018 Richard Bozek 78002 Lago Drive La Quinta, CA 92253 Richard Bozek PO Box 2603 Orange, CA 92859 -771i�� f Re: Violations of La Quinta Municipal Code: 78002 Lago Drive Dear Mr. Bozek: Noam Duzman Direct Dial: (714) 641-3478 E-mail: nduzman a( rutan_com RECEIVED MAR 0 7 2018 CITY OF LA QUINTA COMMUNITY DEVELOPMENT It has come to our attention that you are the owner, occupier, or have a legal interest in the property located at 78002 Lago Drive in the City of La Quinta ("Property"). We have been informed that there are several ongoing La Quinta Municipal Code ("LQMC") violations on the Property relating to unpermitted work. Under the LQMC, the owner/occupier of a property is responsible to ensure that the Property is in compliance with all applicable codes and standards for a property within the City. The City has made an exhaustive administrative effort to obtain voluntary compliance from you including notifying you by way of several notices of violations and citations over a number of years. However, while you have had more than a reasonable amount of time to remedy the violation, you have not done so. At this point, the City has turned the case over to our office, acting in the capacity of City Attorney for the City of La Quinta, to handle this matter. The Property is in violation of the following sections of the LQMC: 1. The Property is in violation of LQMC § 8.02.010 (incorporating by reference the California Building Code, including section 105.1 thereof) by conducting building activity without the benefit of the required permit. There are numerous improvements that have been performed on the Property without a permit or a permit that has been finaled. In order to avoid further enforcement action, you are required to contact my office no more lit an 7 da ys fhom the date of this letter. j d Anton Blvd., Suite 1400, Costa Mesa, CA 92626 Sox 1950, Costa Mesa, CA 92628-1950 1 714.641.5100 1 Fax 714.547.9035 1ge County I Palo Alto I www.rutan.com 975/015610-0015 12013106.1 207J16/18 RECEIVED IIAR 0 7 2018 WY�/ Y OF LA QUIMTA 9D Q �bt �IA�1i1t�Yt 3+' DEVELOPMENT •fir ZNJI-) III��.'i j/ J C ,vc/ ifla-s-e- -- C6( /v P,tpoeK ou4c.2 G.k3g--1 iS 4i✓6) 'e, c- ePto,. E 760 4�6SF� -rA-r4m- City of La quinta A.J. Ortega, Building Official 78-495 Calle Tampico La Quinta, CA 92253 RE: 78002 Lago Drive, La Quinta RECEIVED MAR 2 7 2018 CITY OF LA QUINTA COMMUNITY DEVELOPMENT Last week I was at your office to address why there was a claim that my permit was not properly closed. I was shocked to hear this claim after performing all that Burt Hanada requested and him telling me that he closed this matter. You indicated that due to Burt Hanada passing away, you were acting in his place. You had met with me before at Burt's office and had knowledge that I was working directly with Burt. You know that other City personal who acted wrongfully resulting in Thomas Hartung to intercede. Therafter I was directed to Burt Hanada. Mr. Hartung and Mr.Hanada wanted the conflict resolved with any hearings or litigation. I agreed to work direct with Mr. Hanada and agreed to relinquish filing any claim against the city. I fully cooperated with Mr. Hanada and was told that this matter was resolved and closed. You recalled the incident with the city personal and you found what I said in Burt's/City/my file. You said you had no reason to doubt what we discussed yet the Code Enforcement Division had my permit still outstanding. This is the Cities administrative problem, not ours. You indicated that you wanted to help close this entire matter and so do we. I was at your office because the City Attorney asked me to discuss this matter with you. I told you after this matter with City was resolved, I wanted to get involved with the City as a volunteer. I mentioned to Burt and you, I was not looking for employment but wanted to volunteer on the Community Service Committee. Burt said to me that it would also help to get to know city personal. Burt knew that I do a lot of volunteer work at St. Francis of Assisi Catholic Church and we wanted to build that youth activity center. I mentioned to you, that the person who handles much of the building issues, is about to become a Deacon. After his ordination, his employment by the parish will be in conflict with Diocesan rules. Bishop Barnes will resolve this but I will be involved helping to get this building built on our parishes campus and wanted a good relationship with the City. After leaving your office, I mentioned our meeting to other long time parishioners and the observation was any City Official handling my permit would not let it go unresolved for years. It goes against common judgment and procedure of any City. I received no notices from the City in years. You have work for and with Burt Hanada for years; and I don't think you will say Burt Hanada, or a notice from the City of La Quinta, would not been sent to me, if this was not resolved. You know Mr. Hanada would and so too would the City. was very frank and open with you. I even mentioned the one extension I was late on my renewal and paid the City the fine and had my extension renewed. Burt Hanada �ew this and said he would handle extensions and or code enforcement in that he was the supervisor and was controlling my permit file. If Mr. Hanada did not notify Code Enforcement as he stated he would, I will pay the City one Hundred dollars for an administrative fee for a late extension just to get this matter closed again. A.J., you have sufficient information in the City file, or in Burt's file to close this matter. I am requesting that your do so. If the City wants to default on its agreement with us, and force legal action, we have no choice but to call all the personal who have been involved, to a hearing, to show, what occurred. Richard Bozek 78002 Lago Drive, La Quinta CA. 760 464-8586 MAR 2 7 2018 CITY OF LA 001NI'VA COMMUNITY oL-Vr,--L0I-tVIENT A� f c ruA► 4 Pei lid cJ,� s rQkF 6Q e J L / I f �� & 1"i , � k Ilt'(A � 3 0, (A o / 7 �JC C G AIMI 0 1 OYA 4c i�S ,)rjOc (oP,(,sok-� d6ri lYkC AAd AEq&_X 6f,;eowed _-ri,,,wdS Aj cvm � �,y� //< ci .. PIA�.s. old �;� a _� _eN11RGd�sC �v �r2�� . �1�� ,,N v f ��a��"'__ �, �-e..-7i✓��_��2�aJ _j�_��l_��1 A A ij i� e� �, ��._t.f �6►� •�� i -�e�.S _. �� nLer�rr� f Clo e_ �`� � � ��'L ��t'< <e ties Icd 5 I Aa j k4 —A, pwcr,��-4 P/CPST, exk-tld (4111OP4 4,,1 r,:�e - jza1 + OIl oq-) oc g.p/p-rjQc or -v �Ny cj�,r,\Pk [�,, j Ix- (e C-5 A A �u d'e /,JcLIg�4cLc-tv C R fl"q. IZ S � IZe. tJo 0 �+ rJ\, .s �P tc�- 4 ( F ��o l6i 1��I �► N �114� �L�L� C�� ,' rr/.� � 0�� Ly C'R � C,� o� K AJ4IQ J � 6A kid oil,_ C-01, Tv r� ��S 7'^� _ �CS��II� /SSG`�S ��fi 2S �6Z►_C� 1� �v o�� dWN��,. SUMMONS You are summoned to appear for JURY SERVICE beginning on the date indicated. Bring this summons with you. JUROR PARKING PERMIT DISPLAY ON VEHICLE DASHBOARD BADGE:024733197 GROUP:110 Date; 06/03/19 Indio Courts of Riverside Co. ,l DETACHHERE J T KEEP TOP PORTION T of the Jury Commissioner .4620B Oasis Street - Rm. 213 4ndlo, CA 92201-5933 110 06/03/19 32 02all M11fu111111111111111111I111 00111111logo4I II1I111111111 ENDF :02+4733197 GROUP:110 i FT: 05"19 ALL COURT i_OCATIOW: 7W-342-M or 951-275-5076 wwW-Wa'A a.=9ts.Ca.9DV ONE -DAY or ONE -TRIAL THIS IS YOUR REPORTING ADDRESS. Please mail all correspondence to the address listed on the front of the summons. Indio Court, Jury Assembly Room 213 46200 Oasis Street Indio, CA 92201 Phone: 760-342-6264 or 95 ! -2 �v�5fJ7tY'' PLEASE NOj : If you. have rc�ussled ati �case or dlsqualificatigA. you will need is our aVlomated phonelntemOlzptem 14 days a'f& ini��$`aaal request fo verify if h waslgra*d or derdeij.Tti s a otconflrmat on is not sent by thd`Court. If you are qualirie f tc. n'f� af- requesting an excuse, please bring this entire torhi with -you when you report DO NOT RETURN THE FORM B)' MNL. I RETURN BOTTOM PORTION I J DETACH HERE J Summons for Jury Service ClMt(an de jur7dn SUPERIOR COURT OF CALIFORNIA County of Riverside 9*******5-DIGIT 92253 2120 Richard Bozek 78002 Lago.Dr La Quinta, CA 92253-2705 - Failure to respond to this summons may subject you to a fine, a jail term or both. 7- JU col e Cam°%e� A �e �� C ►L� GJ► fk 01 e A A /v k . /CIOFkor�,, C-, a A) A �� Ct Ri✓ eA�l �/ A01 �"rR�cs la A K. -- ., i _ r� a1 T—.��—d C /_ r r� f ,&A9A - - .Qrjs f 4 �. y ]] V /,.,i, �T Ole All•� X /�� L !� Xi?fl. •. k k SA) ,oj4 �T J/ 1 llwu ggcf,-.- P U� 4/,c. kfegae� August 9, 2019 ReJames Wiatrak City of La Ouinta I along with Mr. Gleason were at your office this morning. As we promised once all revisions and supportive documents were obtained, I would bring them to you directly. When we were advised you were out of the office, we left with all documents because there was a couple of items, I wanted to point out to you. The HOA compliance letter which set forth my full compliance with rules, regulations and architechtual guidelines was obtained. This document is placed into may revised packet. The HOA Board members being out of town, took me time to locate them and have my property checked and validated. As for the issue of a "wet signature on the structural drawings and calculations that were rejected by the City of La Ouinta; I request Core Civil and Structural Engineering to contact the city directly. I have attached (#1), an email response from Robert Style, Chief Operating Officer, dated July 24, 2019. He set forth, California Civil Code, Title 16, Division 5 sections 400- 476. He points out to planning review that section 411, (e) , states,"The seal shall be capable of leaving a permanent ink representation, a permanent impression, or a electronically -generated representation the document. The signature may be applied to the documents electronically." Also attached, (#2 ), is California Civil Code Section 1633.7,(a) " A record or a signature may not be denied legal effect or enforceability soley because it is in electronic form. " Section 1633.7(b,c,d),are also attached. I will come into your office next week to get confirmation from you that my packet is in proper order. I personally will be hand carrying all documents to my contractor or any third party to avoid any delay. My wife has been placed on "Palliative Care", and we have treatments set by her doctors starting again in September and October, 2019. We have being trying to obtain everything the City has requested but many items occured years before we owned the property. All this emotional and Q w _> v) O N UJo= O UCM w� financial pressure is having a harmfull effect on the lives of my wife and myself. We Zhhe this will satisfy the City of La Ouinta. hX Ri hard YAHOO!MAIL Subject RE: Wet signature? 71002 Lago Dr. LQ From Robert Style <robert@corestructure.com> To: < Date Wed, Jul 24, 2019 at 4.38 PM Amir from our office has left several messages without return call. Here is the section... Board Rules and Regulations Relating to the Practices of Professional Engineering and Professional Land Surveying California Code of Regulations Title 16, Division 5 §§ 400-476 Sec. 411 (e) The seal shall be capable of leaving a permanent ink representation, a permanent impression, or an electronically -generated representation on the documents. The signature may be applied to the documents electronically. CC-) RE Civil and Structural Engineering Robert Style Chief Operating Officer 23172 Plaza Pointe Dr. #145 Laguna Hills, CA 92653 Office: 949-954-7244 custom search LJ 11Q= I Ft&aL rld_aWie hays I =[Qm6LL;3wj I C4rL1S.951v I 1 ilifornlacivil Code Seel ion 1623.7 California Civil Code Section 1633.7 P>X Free Employment Law Consult Wrongful Termination Lawyer (Millions Recovered) What Con"tute Wrongful Job Term6rallon? Ask Our L Experts Now. yourwaftbvsrtyrmran DFEri CA Civ Code § 1633-7 (2017) (a) A record or signature may not be denied legal effect or enforceablity solely because it is in electronic form. (b) A contract may not be denied legal effect or enforceability solely because an electronic record was used in its formation. (c) If a law requires a record to be in writing, an electronic record satisfies the law. (d) If a law requires a signature, an electronic signature satisfies the law. (Added by Slats.1999 CIL 424 Sec_ 1. Effective January 1, 2000.) L r LGyjaU 1633.1 1633.2 16333 1633 3 a 1633.4 16315 103.6. EElfa33.$ 1833.9 103,70 it 1 G33_71 ling 12 112 tf.1 ®X Free Employment Law Consult Wrongful Termination Lawyer (Ml k= Recovered) What Constitute Wrongful Job Termination? Ask our L Experts Now. yOlMY/011�IBClMig11b.0on1 OPEN Last modified: October 25, 2018 State Laws Alabama Alaskg Mma CulHnmia Flnrda .Etgla lutnal€ Indlaaa Mit3Snchusem Mifmi9an t1evado NewJerscy No York Ohio UMM P.nnsykanla Seaga Yllgigl& YtlushinCLEM Court Opinions US Sup!eme Court !IS Tax Court Board of Patent Anneals Federal Laws us code !1S CoASlilur;en AnJ - EcoIsiallve Art. I I - Execultye An-MZ1012101 Art. IV - States' Relations ALtVIUaMI l LuYvIll g CERTIFICATE OF COMPLIANCE - RESIDENTIAL PERFORMANCE COMPLIANCE METHOD Project Name: Residential Building Calculation Date/Time: 09:11, Fri, Sep 06, 2019 CFI R-PRF-01 Page 1 of 9 Calculation Description: Title 24 Analysis Input File Name: L r 03.05.19.ribd16x M41 GENERAL INFORMATION 01 Project Name Residential Building 1 02 Calculation Description Title 24 Analysis 03 Project Location 78002 Lago Dr 0 04 City La Quinta Qj (0 Standards Version Compliance 2017 06 Zip Code 92253 �1 ompliance Manager Version BEMCmpMgr 2016.3.1 (1149) 08 Climate Zone CZ15 "09 _� �Qs Software Version EnergyPro 7.2 10 Building Type Single Family _ �ront Orientation (deg/Cardinal) 180 12 Project Scope Addition and/or Alteration A�� 13A Number of Dwelling Units 1 14 Total Cond. Floor Area (ft2) 2707 Number of Zones 2 16 Slab Area (ft2) 2707 17 Number of Stories 1 18 Addition Cond. Floor Area (ft2) 284 19 Natural Gas Available Yes 20 Addition Slab Area (ft2) 284 21 Glazing Percentage (%) 15.6% COMPLIANCE RESULTS 01 Building Complies with Computer Performance 02 This building incorporates features that require field testing and/or verification by a certified HERS rater under the supervision of a CECapproved HERS provider. 03 This building incorporates one or more Special Features shown below ENERGY USE SUMMARY 04 05 06 07 08 Energy Use (kTDV/ft2-yr) Standard Design Proposed Design Compliance Margin Percent Improvement Space Heating 3.72 4.20 -0.48 -12.9% Space Cooling 91.82 90.43 1.39 1.5% IAQ Ventilation 0.00 0.00 0.00 0.0% Water Heating 8.81 8.81 0.00 0.0% Photovoltaic Offset --- 0.00 0.00 ---- Compliance Energy Total 104.35 103.44 0.91 0.9% REQUIRED SPECIAL FEATURES The following are features that must be installed as condition for meeting the modeled energy performance for this computer analysis. • Window overhangs and/or fins • Nonstandard duct location (any location other than attic) Registration Number: 219-P010194390A,000-000-0000000-0000 Registration Date/Time: 2019-09-06 09:15:25 HERS Provider: CaiCERTS inc. CA Building Energy Efficiency Standards - 2016 Residential Compliance Report Version - CF1 R-06232018-1149 Report Generated at: 2019-09-06 09:13:01 CERTIFICATE OF COMPLIANCE - RESIDENTIAL PERFORMANCE COMPLIANCE METHOD Project Name: Residential Building Calculation Date/Time: 09:11, Fri, Sep 06, 2019 CFI R-PRF-01 Page 2 of 9 Calculation Description: Title 24 Analysis Input File Name: Lago Dr 03.05.19.ribd16x HERS FEATURE SUMMARY The following is a summary of the features that must be field -verified by a certified HERS Rater as a condition for meeting the modeled energy performance for this computer analysis. Additional detail is provided in the building components tables below. Building -level Verifications: Cooling System Verifications: • Minimum Airflow • Refrigerant Charge verification required if a refrigerant containing component is altered • Fan Efficacy Watts/CFM HVAC Distribution System Verifications: • Duct Sealing Domestic Hot Water System Verifications: • -- None -- BUILDING - FEATURES INFORMATION 01 02 03 04 05 06 07 Number of Dwelling Number of Ventilation Number of Water Project Name Conditioned Floor Area (ft2) Units Number of Bedrooms Number of Zones Cooling Systems Heating Systems Residential Building 2707 1 1 2 0 1 ZONE INFORMATION 01 02 03 04 05 06 07 Zone Name Zone Type HVAC System Name Zone Floor Area (ft2) Avg. Ceiling Height Water Heating System 1 Water Heating System 2 Zone 1 Conditioned 5T1 2423 10 DHW Sys 1 n/a Addition Conditioned 5T1 284 10 DHW Sys 1 n/a Registration Number: 219.P010194390A-000-000-0000000-0000 Registration Date/Time: 2019-09-06 09:15:25 HERS Provider: CaICERTS inc, CA Building Energy Efficiency Standards - 2016 Residential Compliance Report Version - CF1 R-06232018-1149 Report Generated at: 2019-09-06 09:13:01 CERTIFICATE OF COMPLIANCE - RESIDENTIAL PERFORMANCE COMPLIANCE METHOD Project Name: Residential Building Calculation Date/Time: 09:11, Fri, Sep 06, 2019 CFI R-PRF-01 Page 3 of 9 Calculation Description: Title 24 Analysis Input File Name: Lago Dr 03.05.19.ribd16x OPAQUE SURFACES 01 02 03 04 05 06 07 08 09 10 11 Name Zone Construction Azimuth Orientation Gross Area (ft2) Window & Door Area (ft2) Tilt (deg) Wall Exception Status Verified Existing Condition West Wall Zone 1 R-19 Wall 270 Left 444 49 90 n/a Existing No North Wall Zone 1 R-19 Wall 0 Back 442 276 90 n/a Existing No South Wall Zone 1 R-19 Wall 180 Front 442 0 90 n/a Existing No East Wall Zone 1 R-19 Wall 0 Back 444 0 90 n/a Existing No Roof 2 Zone 1 R-38 Roof Attic 2423 n/a Existing No East Wall (ATRIUM) Addition R-19 Wall 270 Left 128 40 90 none New n/a South Wall (ATRIUM) Addition R-19 Wall 180 Front 48 0 90 none New n/a West Wall (ATRIUM) Addition R-19 Wall 270 Left 128 82 90 none New n/a North Wall (ATRIUM) I Addition R-19 Wall 0 Back 48 0 90 none New n/a OPAQUE SURFACES — Cathedral Ceilings 01 02 03 04 05 06 07 08 09 10 11 12 Name Zone Type Orientation Area (ft2) Skylight Area (ft2) Roof Rise (x in 12) Roof Reflectance Roof Emittance Cool Roof Status Verified Existing Condifion Roof Addition R-38 Roof Cathedral Back 284 0 0 0.1 1 0.85 No New n/a ATTIC 01 02 03 04 05 06 07 08 09 10 Name Construction Type Roof Rise Roof Reflectance Roof Emittance Radiant Barrier Cool Roof Status Verified Existing Condition Attic Zone 1 Attic RoofZone 1 Ventilated 0.2 0.1 0.85 Yes No Existing No Registration Number: 219-P010194390A-000.000-0000000-0000 Registration DateMme: 2019-09-06 09:15:25 HERS Provider: CaICERTS inc. CA Building Energy Efficiency Standards - 2016 Residential Compliance Report Version - CF1 R-06232018-1149 Report Generated at: 2019-09-06 09:13:01 CERTIFICATE OF COMPLIANCE - RESIDENTIAL PERFORMANCE COMPLIANCE METHOD Project Name: Residential Building Calculation Date/Time: 09:11, Fri, Sep 06, 2019 CF1 R-PRF-01 Page 4 of 9 Calculation Description: Title 24 Analysis Input File Name: Lago Dr 03.05.19.ribd16x FENESTRATION / GLAZING 01 02 03 04 05 06 07 08 09 10 11 Name Surface (Orientation -Azimuth) Width (ft) Height (ft) Multiplier Area (ft2) U-factor SHGC Exterior Shading Status Verified Existing Condition window 3 West Wall (Left-270) ---- ---- 1 25.0 0.58 0.53 Insect Screen (default) Existing No Sliding Door C North Wall (Back-0) 6.0 8.0 1 48.0 0.58 0.53 Insect Screen (default) Existing No Sliding Door D North Wall (Back-0) 6.0 8.0 1 48.0 0.58 0.53 Insect Screen (default) Existing No Sliding Door E North Wall (Back-0) 6.0 8.0 1 48.0 0.58 0.53 Insect Screen (default) Existing No window 4 North Wall (Back-0) 6.0 7.0 1 42.0 0.58 0.53 Insect Screen (default) Existing No window 5 North Wall (Back-0) 3.0 7.0 1 21.0 0.58 0.53 Insect Screen (default) Existing No Sliding Door F North Wall (Back-0) 6.0 8.0 1 48.0 0.58 0.53 Insect Screen (default) Existing No window 6 North Wall (Back-0) 3.0 7.0 1 21.0 0.58 0.53 Insect Screen (default) Existing No Sliding Door G East Wall (ATRIUM) (Left-270) 5.0 8.0 1 40.0 0.34 0.33 Insect Screen (default) New n/a Sliding Door A West Wall (ATRIUM) (Left-270) 5.0 8.0 1 40.0 0.34 0.33 Insect Screen (default) New n/a Window 1 West Wall (ATRIUM) (Left-270) 3.0 7.0 1 21.0 0.34 0.33 Insect Screen (default) New n/a Window 2 West Wall (ATRIUM) (Left-270) 3.0 7.0 1 21.0 0.34 0.33 Insect Screen (default) New n/a OPAQUE DOORS 01 02 03 04 05 06 Name Side of Building Area (ft2) U-factor Status Verified Existing Condition Door West Wall 24.0 0.50 Existing No Registration Number: 219-P010194390A-000-000-0000000-0000 Registration DateTme: 2019.09.06 09:15:25 HERS Provider: CaICERTS inc. CA Building Energy Efficiency Standards - 2016 Residential Compliance Report Version - CF1 R-06232018-1149 Report Generated at: 2019-09-06 09:13:01 CERTIFICATE OF COMPLIANCE - RESIDENTIAL PERFORMANCE COMPLIANCE METHOD Project Name: Residential Building Calculation Date/Time: 09:11, Fri, Sep 06, 2019 CFI R-PRF-01 Page 5 of 9 Calculation Description: Title 24 Analysis Input File Name: Lago Dr 03.05.19.ribdl6x OVERHANGS AND FINS 01 02 03 04 05 06 07 08 09 10 11 12 13 14 Overhang Left Fin Right Fin Left Right Window Depth Dist Up Extent Extent Flap Ht. Depth Top Up Dist L Bot Up Depth Top Up Dist R Bot Up Sliding Door C 8 0.1 8 8 0 0 0 0 0 0 0 0 0 Sliding Door D 8 0.1 8 8 0 0 0 0 0 0 0 0 0 Sliding Door E 8 0.1 8 8 0 0 0 0 0 0 0 0 0 window 4 8 0.1 8 8 0 0 0 0 0 0 0 0 0 window 5 8 0.1 8 8 0 0 0 0 0 0 0 0 0 Sliding Door F 8 0.1 8 8 0 0 0 0 0 0 0 0 0 window 6 8 0.1 8 8 0 0 0 0 0 0 0 0 0 Sliding Door G 6 0.1 6 6 0 0 0 0 0 0 0 0 0 Sliding Door A 6 0.1 6 6 0 0 0 0 0 0 0 0 0 Window 1 6 0.1 6 6 0 0 0 0 0 0 0 0 0 Window 2 6 0.1 6 6 0 0 0 0 1 0 0 0 0 0 OPAQUE SURFACE CONSTRUCTIONS 01 02 03 04 05 06 07 Total Cavity Winter Design Construction Name Surface Type Construction Type Framing R-value U-factor Assembly Layers • Cavity/Frame: no insul. /2x4 Top Chrd 2x4 Top Chord of Roof Truss @ 24 • Roof Deck., Wood Siding/sheathing/decking Attic RoofZone 1 Attic Roofs Wood Framed Ceiling in. O.C. none 0.644 • Roofing: Light Roof (Asphalt Shingle) • Inside Finish: Gypsum Board R 19 in 5-1/2 in. • Cavity/Frame: R-19 in 5-1/2 in. (R-18) /2x6 R-19 Wall Exterior Walls Wood Framed Wall 2x6 @ 16 in. O.C. cavity (R-18) 0.074 - Exterior Finish: 3 Coat Stucco • Inside Finish: Gypsum Board Ceilings (below • Cavity/Frame: R-9.1/2x4 R-38 Roof Attic attic) Wood Framed Ceiling 2x4 @ 24 in. O.C. R 38 0.025 , Over Ceiling Joists: R-28.9 insul. • Inside Finish: Gypsum Board • Cavity/Frame: R-38/2x6 • Roof Deck: Wood Siding/sheathing/decking R-38 Roof Cathedral Cathedral Ceilings Wood Framed Ceiling 2x6 @ 16 in. O.C. R 38 0.036 • Roofing: 15 PSF (Heavy Ballast or Pavers) Registration Number: 219-P010194390A-000-000-0000000-0000 Registration Date/Time: 2019-09.06 09:15:25 HERS Provider: CaICERTS inc. CA Building Energy Efficiency Standards - 2016 Residential Compliance Report Version - CF1 R-06232018-1149 Report Generated at: 2019-09-06 09:13:01 CERTIFICATE OF COMPLIANCE - RESIDENTIAL PERFORMANCE COMPLIANCE METHOD Project Name: Residential Building Calculation Date/Time: 09:11, Fri, Sep 06, 2019 CF1 R-PRF-01 Page 6 of 9 Calculation Description: Title 24 Analysis Input File Name: Lago Dr 03.05.19.ribdl6x SLAB FLOORS 01 02 03 04 05 06 07 08 09 Name Zone Area (ft2) Perimeter (ft) Edge Insul. R-value Carpeted Fraction Heated Status Verified Existing Condition Slab -on -Grade Zone 1 2423 0.1 None 1 No Existing No Slab -on -Grade 2 Addition 1 284 0.1 None 1 No New No BUILDING ENVELOPE - HERS VERIFICATION 01 02 03 04 Quality Insulation Installation (QII) Quality Installation of Spray Foam Insulation Building Envelope Air Leakage CFM50 Not Required Not Required Not Required n/a WATER HEATING SYSTEMS 01 02 03 04 05 06 07 08 Name System Type Distribution Type Water Heater Number of Heaters Solar Fraction N Status Verified Existing Condition DHW Sys 1 DHW Standard DHW Heater 1 1 0 Existing I No WATER HEATERS 01 02 03 04 05 06 07 08 09 10 11 12 Input Rating / Tank Standby Heater Tank Uniform Energy Pilot / Insulation Loss / First Hour Tank Location Element Number Volume Factor / Energy Thermal R-value Recovery Rating / NEEA Heat Pump or Ambient Name Type Tank Type of Units (gal) Factor / Efficiency Efficiency (Int/Ext) Eff Flow Rate Brand / Model Condition DHW Heater 1 Gas Small Storage 1 50 0.525 EF — 75 kBtu/hr 0 n/a n/a n/a n/a SPACE CONDITIONING SYSTEMS 01 02 03 04 05 06 07 08 SC Sys Name System Type Heating Unit Name Cooling Unit Name Fan Name Distribution Name Status Verified Existing Condition 5T1 Other Heating and Cooling System Heating Component 1 Cooling Component 1 HVAC Fan 1 Air Distribution System 1 Existing No Registration Number: 219-P010194390A-000-000-0000000-0000 Registration DateMme: 2019-09-06 09:15:25 HERS Provider: CaICERTS inc. CA Building Energy Efficiency Standards - 2016 Residential Compliance Report Version - CF1 R-06232018-1149 Report Generated at: 2019-09-06 09:13:01 CERTIFICATE OF COMPLIANCE - RESIDENTIAL PERFORMANCE COMPLIANCE METHOD Project Name: Residential Building Calculation Date/Time: 09:11, Fri, Sep 06, 2019 CF1 R-PRF-01 Page 7 of 9 Calculation Description: Title 24 Analysis Input File Name: Lago Dr 03.05.19.ribdl6x HVAC - HEATING UNIT TYPES 01 02 03 04 Name System Type Number of Units Efficiency Heating Component 1 CntrlFurnace 1 93 AFUE HVAC - COOLING UNIT TYPES 01 02 03 04 05 06 07 08 Name System Type Number of Units Efficiency EER SEER Zonally Controlled Compressor Type HERS Verification Cooling Component 1 SplitAirCond 1 1 1 -7 11 T16 Zonally Controlled Multi -speed Cooling Component 1-hers-cool HVAC COOLING - HERS VERIFICATION 01 02 03 04 05 06 Name Verified Airflow Airflow Target Verified EER Verified SEER Verified Refrigerant Charge Cooling Component 1-hers-cool Required 350 Not Required Not Required Required" Refrigerant Charge verification required if a refrigerant containing component is altered HVAC - DISTRIBUTION SYSTEMS 01 02 03 04 05 06 07 08 09 10 Insulation Supply Duct Return Duct Verified Existing HERS Name Type Duct Leakage R-value Location Location Bypass Duct Status Condition Verification Air Distribution Ducts located in outdoor Air Distribution System 1 locations Sealed and tested 8.0 Outside Outside None New No System 1-hers-dist HVAC DISTRIBUTION - HERS VERIFICATION 01 02 03 04 05 06 07 08 Name Duct Leakage Verification Duct Leakage Target (%) Verified Duct Location Verified Duct Design Buried Ducts Deeply Buried Ducts Low -leakage Air Handier Air Distribution System 1-hers-dist Required 5.0 Not Required Not Required Not Required Not Required n/a Registration Number: 219-P010194390A-000-000-0000000-0000 Registration DateTme: 2019-09-06 09:15:25 HERS Provider: CaICERTS inc. CA Building Energy Efficiency Standards - 2016 Residential Compliance Report Version - CF1 R-06232018-1149 Report Generated at: 2019-09-06 09:13:01 CERTIFICATE OF COMPLIANCE - RESIDENTIAL PERFORMANCE COMPLIANCE METHOD Project Name: Residential Building Calculation Date/Time: 09:11, Fri, Sep 06, 2019 CFI R-PRF-01 Page 8 of 9 Calculation Description: Title 24 Analysis Input File Name: Lago Dr 03.05.19.ribd16x IAQ (Indoor Air Quality) FANS 01 02 03 04 05 06 Dwelling Unit IAQ CFM IAQ Watts/CFM IAQ Fan Type IAQ Recovery Effectiveness(%) HERS Verification SFam IAQVentRpt 0 0.25 Default 0 Not Required Registration Number: 219-P010194390A-000-000-0000000-0000 Registration Date/Time: 2019-09-06 09:15:25 HERS Provider: CaICERTS inc. CA Building Energy Efficiency Standards - 2016 Residential Compliance Report Version - CF1 R-06232018-1149 Report Generated at: 2019-09-06 09:13:01 CERTIFICATE OF COMPLIANCE - RESIDENTIAL PERFORMANCE COMPLIANCE METHOD Project Name: Residential Building Calculation Date/Time: 09:11, Fri, Sep 06, 2019 CFI R-PRF-01 Page 9 of 9 Calculation Description: Title 24 Analysis Input File Name: Lago Dr 03.05.19.ribd16x DOCUMENTATION AUTHOR'S DECLARATION STATEMENT 1. 1 certify that this Certificate of Compliance documentation is accurate and complete. Documentation Author Name: Documentation Author Signature: Bob Sipovac DAA-5y Company: Signature Date: SIPOVAC CONSTRUCTION INC 2019-09-06 09:15:25 Address: CEA/HERS Certification Identification (If applicable): 72651 THEODORA LANE City/State/Zip: Phone: PALM DESERT, CA 92260 760-567-2347 X123 RESPONSIBLE PERSON'S DECLARATION STATEMENT I certify the following under penalty of perjury, under the laws of the State of California: 1. I am eligible under Division 3 of the Business and Professions Code to accept responsibility for the building design identified on this Certificate of Compliance. 2. 1 certify that the energy features and performance specifications identified on this Certificate of Compliance conform to the requirements of Title 24, Part 1 and Part 6 of the California Code of Regulations. 3. The building design features or system design features identified on this Certificate of Compliance are consistent with the information provided on other applicable compliance documents, worksheets, calculations, plans and specifications submitted to the enforcement agency for approval with this building permit application. Responsible Designer Name: Responsible Designer Signature Bob Sipovac'�� Company: Date Signed: SIPOVAC CONSTRUCTION INC 2019-09-06 09:15:25 Address: License: 72651 THEODORA LANE 581636 City/State/Zip: Phone: PALM DESERT, CA 92260 760-567-2347 X123 Digitally signed by CaICERTS. This digital signature is provided in order to secure the content of this registered document and in noway implies Registration Provider responsibility for the accuracy of the information. Registration Number: 219-P010194390A-000-000-0000000-0000 Registration Date/Time: 2019-09-06 09:15:25 CA Building Energy Efficiency Standards - 2016 Residential Compliance Report Version - CF1 R-06232018-1149 HERS Provider: CaICERTS inc. Report Generated at: 2019-09-06 09:13:01 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 build permit has been s tted in ya name lis ' yourself as the builder of the property improvements specified at? � 4 We are providing you with an Owner -Builder knowledgment 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 MORMATION DIRECTIONS: Read and initial each statement below to sign6 you understand or verb this information. 4LI. 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. j_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. 0 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 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. KJJ 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. V-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: M11. 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. 916 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 issuin ermit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to a is requir d to b7 presented when the permit is issued to verify the property owner's signature. � Signature of property owner _ _ Date: "��_�� 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 persons) 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 owner's signature. Property Owner's Signature: _ _ Date: CERTIFICATE OF COMPLIANCE Desert Sands Unified School Districto�•#°� 47950 Dune Palms Road Date: 9/12/2019 La Quinta, CA 92253 ¢1. ArOAA� 0- No.: 19-01468-1 (760)771-8515 Owner: Richard Bozek Email: Address: 78-002 Lago Dr Jurisdiction: La Quinta City: La Quinta Tract #: Type: Residential Addition < 500 Sq ft Lot # Street No. Street Name Sq. Feet APN Permit No. 78-002 Lago Dr 284 658-270-034 RECEIVED SEP 13 2019 CITY OF LA QUINTA DESIGN AND DEVELOPMENT DEPARTMENT Comments: 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 284 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 p xem t Richard Bozek Check No.: Bank Name/Recipient of Certificate Telephone: 760-464-8586Funding: Exempt By Scott L. Bailey Superintendent Fee Collected/ Exempted by: Arianne Catano Certificate Fees Due: $0.00 Original Payment(s) Rec'd: $0.00 New Payment Rec'd: $0.00 Over/Under.- $0.00 NOTICE: Pursuant to Government 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 payment 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. CITY OF LA QUINTA SUB -CONTRACTOR, LIST TDB ADDRESS PERMIT NUMBER (WjES 2-0lg_&4pWNER C _ �, BUILDER r This form shall be posted on the job 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 the voidance of building permit. For each applicable trade, all information requested below must be completed by applicant. "On File" is not an acceptable response. Tra.de.).Classilication. Contractor .. -State Contractor's License Workers Compensation Insurance City Business License Company Name Classification (e.g. A, B, C-8) License Number (xxxxxx) Exp. Date (xx/),x/xx) Carrier Name (e.g. State Fund, CalComp) Policy Number (Format Varies) Exp. Date (xx/xxlxx) License Number (xxxx) Exp. Date (xx/xx/xx) EARTHWORK (G-12) CONCRETE (C-.8) (G-5) STRVGT. STEEL (0-511 r A G i 1AYWFRAMING MASO. NRY :(C 29:) PLUMBING (C-36) LATH, PLASTER (C-3:5 ) DRYWALL (C-9) -CIel I C HVAG (C-201 ELECTRICAL {G-1:0): :ROOFING IC-39:) SHEET METAL (C-.43:): FLOORING (C-15:) GLAZING (C717) INSULATION (C-2) SEWAGE DISP. (C-42) PAINTING: (C-33.) I� CERAMIC TILE (.C-54) CABINETS (C:-6) FENCING (C-13) :LANDSCAPING :(C-27) POOL (C-53)