DRVA2017-0015S • S IIuJ .q7
LUNRY'LM QUJNTA
S.. PATME
DRIVEWAY APPROACH PERMIT APPLICATION
Applicant Information:
Applicant/Owner (please pjjQ.t name here): AV1C.i y Sco f4e12fl
Applicant Address: o £0 viesb
Number Street City Stat
Address or Parcel No. of work location, if different from applicant's address above:
cct Vc2S..?
Zip Code
Number S Street City State Zip Code
Date: ..i.Jj / Applicant's Phone No: (7 0) - 290o
Applicant's Signature:
Approximate Start Date: i 47 Approximate Completion Date: i'I
Contractor Information:
Address: bi)t(cr
Number Street City . State Zip Code
Phone Number: ( . Contractors License Number:
City Business License Number:
General Liability Insurance Company: S Policy No.
:R 0)-7774-0-9-1—before requesLanJnspectiGiii'IëiT24...J
'hours'pnortbyOur requStëd 1_êtiO_ate._Thk!ubCounter(Z6O)-lZ7g.i2 ) S
Please Note: Inspections are normally performed Monday through Friday between 8am and 4pm
Permit Fee $152 + $5 Technology Enhancement Fee = $157 Total Fee
Permit No. Expiration Date
Permit Issued by: Date Issued C—_/4
Work Inspected by: Permit Completion Date: //
Inspector's Signature
Comments:
Note: Driveway approach must be constructed per City of La Quinta Standard#221
tev Qai
GEM of ihe DESI
PROPERTY OWNER'S PACKAGE
Disclosures & Forms for Owner-Builders Applying for Driveway Permits
IMPORTANT! NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a driveway permit for work within the public right-of-way has been
submitted in your name listing yourself as the builder of the driveway improvements
specified at _7'10 jove..+A W.'I
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
driveway 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.
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.
I understand driveway 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.
oh. 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 flied in his or her .name instead of my own.
04. I understand Contractors are required by low to be licensed and bonded in California
and to list their license numbers on permits and contracts.
1141 5. 1 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.
fit7. 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.
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.
I am aware of and consent to an Owner-Builder driveway 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:
111 40 sorc4z u)i L cj "izzc
"1O. 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
,
Nner-Builders as well as employers.
iy
0!— 11.1 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 driveway 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 tile properly owner's driver's license, form notarization, or other
verification acceptable to the agency is required to be presented when the permit is
issued to verify the property owner's signature.
Signature of property owner: 19yJaZ=____ Date: 3A
78-495 Calle Tampico La Quinta, CA 92253 760.777.7000