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Courtesy slab insp.BIA # City. of La Quinta Bull&.. a Safety Division P.O. Box 1504,78-495 Cafie Tampico La.Quinta, CA 92253 -:(760) 777-7012 Building Permit Applicatioaand Tracking Sheet Permit # Com. Project Address: LOwner's Name:. Address: 19 .• 1 � Za � H. T . City, ST, Zip: L 6 V i hT 4 CA . 2 r, Telephoner O_ A. P. Number. Legal Description: Contractor. Address: Project Description: City, ST, Zip: n Telephone:14 State Lic. # : City Lie. #; Arch., Engr., Designer Address: City., ST, Zip: Telephone: State Lic. #: � � • � '•. .:w�i...... % Construction Type- Occupancy: Project type (circle one) New dd'n Alter Repair Demo Name of Coataq Person: Sq. Ft.: #Stories: #Units: Telephone # of Contact Person: Estimated Value of Project: APPLICANT: DO NOT WRITE BELOW THIS UNE # Submittal Plpn Sets Req'd'Rec'd TRACMG Pian Cheek submitted 5 01— PERMIT FEES Item Amount Structural Coles. Reviewed, ready for corrections Ilan Check Deposit. . Tess Calcs• Called Contact Person Plan Check Balance Mile 24 Calci. Pians picked uP Construction Flood plain plan Plans resubmitted Mechanical Grading plan 2•r Review, ready for correctionstiissue Electrical Subcontactor List Called Contact Person Plumbing Grant Deed Plans picked up H.O.A. Approval Plans resubmitted Grading DY HOUSE:- Review; ready for corrections/issue Developer Impact Fee Planning Approval. Called Contact Person Ad.P.P. Pub: Wks. Appr - Date of permit issue School Fees Total Permit Fees a / I 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, fo.r Owner-B.uIlders Applying for Construction Permits, MQ.RUNT1 NOTICF Tn PR[tP� 'Tj� OSE Dear Property Owner: Ari. application for a building pesrmit has been submittediii your name listing yourself as the builder of the .property improvements specified at IR -11A Rw r tle LA4 c..T- We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you awam of your respensbilities and possible risk you may incur by halving this permit ismed in your name as .the Owner -Budder. We will not Issue a building -permit until yowhave read, initiated your understanding of each'provision, signed, and returned this form to us at our official address indicated. An agent of the owns cannot execute oris notice unless you, the property owner, obtain the prior approval of the permitting authority. O"� AeIGN iV i ED N'T AM �E ')�("'A'1 IQN OF U2V0 DAVX'W S. Read andinitial each statement-etow-to signify you undwsiand or dere+ this information. =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 persona f+. 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. 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. 9 s. an 3. I understand a"Owner-Builder" I am the responsible of record on the permit I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. A5. 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. i 6. 1 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' condensation 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.. isk 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. S -T 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. 4uries sumined by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. ' IM9. 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 (CkR) at 1- 800-321-CSLB (2752) or www.cslb.ca gov for more information about licensed contractors. 0. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the ply legally and f nancially responsible . for proposed construction activity at the following address: !E�l l_ I agree that, as the party legally and ftnancially responsible for this proposed construction activity,.t will abide by all applicable liws and requirentents that govern Owner -Builders as well as employers. agree to notify the issuer of this form immediately of any additions ; deletions, of ch"ges to any of die informadw 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 finanaiat loss you may sustain as a result of a complaint Your only remedy against unlicensed Contractors may be inVivit court. It is also important for you toy understand that if as unlicensed.Contraetor of employee of that individual of firm is injured white W011dag on your property; you may be held Mable; for damagees, if you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responstMo for verifying, vAtetbw or not those Contractors are property licensed and the slants of their wor&eW compensation insuran©e 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 issu€ag; dw.P"=lt. lli • A py, of eke prope;V owner's MveesRbeMri forvts aota>a nt or other verification aeccpdrble to the ancy req be preserved when flee pcvn t is iawd toverify the property owner's signature. Signatures of property Date- S ( 2 Note: The following Authorization Fortis 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. AUT$ORIZATION OF AGENT TO ACT ON PROPERTY O'TTER'S BEHaF Faccluding.the Notice to Property Owner, the exewtion of which I understand is my personal responsibility, I hereby authorize the following person(O 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 ddress: Name of Authorized Agent: Address of Authorized Agent: Tel No I declare under penalty of perjurythat 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 Co be presented when the permit is issued to verify the property owner's signa(ure. Property Owner's Signature: Date: �a�►T1����0 7