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DRVA2017-00214uida -GEMof,I,e DES UV---- lu DRIVEWAY APPROACH PERMIT APPLICATION- -' 4VJI IP Applicant Information: Applicant/Owner (please pEit name here): I,14 iL/Cl t o A14 VA Applicant Address: 1) . QJ-rk(aio CISc C7) 7C 2.- Number Street City State Zip Code Address or Parcel No. of work location, if different from applicant's address above: /çj(- Lk i)1 lJTA cPc- Number Street City State Zip Code Date: f.Qij T? Applicant's Phone No: ('tO'/) 70 I 0 Applicant's Signature: i...- .. Approximate Start Date: iO,..ji/? Approximate Completion Date:"/ 0 0 17 Contractor Information: Address: Oc)AJ(2- co, Number Street City I State Zip Code Phone Number: (_____ Contractors License Number: -t C City Business License Number: General Liability Insurance Policy No. Request for Inspection - Please call (760) 777-7097 before 1:30pm to request an inspection at least 24 hours prior to your requested inspection date. The Hub Counter (760)7.7-7125. Please Note: Inspections are normally performed Monday through Friday between Barn and 4pm Permit Fee $156 + $5 Technology Enhancement Fee = $161 Total Fee DateI//jZ . Permit No. tRti4.2jI °3/ Permit Issued Date Issued (01j11j7 ignatu ejf dmiisr&ive AuthoritT Work Inspected by: Permit Completion Date: Inspector's Signature Comments: . . Note: Driveway approach must be constructed per City. of La Quinta Standard #221 - GIMqr/wflEsIkT'.— 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 c1 9 1 &I'lem 154 Fk-hU-k 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. 2. 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. EJI . 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. 104. 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. 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 On "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 !ious financial risk. '-J7. 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 BenefitPayments, 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 out licensed contractors. I am aware of and consent to an Owner-Builder driveway permit applied for in my name, and understand that Jam the party legally and financially responsiblefor proposed construction.activify at the folloWMaas - ZiJ 10. 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. 'Jff.I ii. 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 on 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 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. Signature of property owner: Date: i 0 (s/i 78495 Catle Tampico La Quinta, CA 92253 760.777.7000 Note: The following ,4uthor12ation 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. 0 S 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 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): S Project Locafion 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 to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: 78-495 Catle Tampico La Quinta, CA 92253 0 760.777.7000 H . -- GEM afth DESERT -. - DRIVEWAY APPROACH PERMIT APPLICATLON— Applicant Information: Applicant/Owner (please rkit name here): &iL/ei cIc- A14 VA Applicant Address- ~~~ L4i. 54 0'JiR0o C/Sc Number Street City State Zip Code Address or Parcel No. of work Location, if different from applicant's address above: 51I /CVkWit'(+ AA LPc QL)uJTA CA- Number Street Gity State Zip Code Date: 10 1 -7 Applicant's Phone No i09). 70 I 0 Applicant's Signature: Approximate Start Date: L.J....iiJ2 Approximate Completion Date: j.2....'.L..jj2 Contractor Information: Address: Number Street City State Zip Code Phone Number: ( Contractors License Number: C) City Business License Number: General Liability Insurance Company:. Policy. No. Request for Inspection - Please call (760) 777-7097 before 1:30pm to request an inspection at least 24 hours prior to your requested inspection date. The Hub Counter (760)777-7125. Please Note: inspections are normally performed Monday through Friday between 8am and 4pm Permit Fee $156 + $5 Technology Enhancement Fee = $161 Total Fee Permit No. t4&2bi7-?l ExPpt)Pat//) I_/J_2 Permit Issued by: j2?II Date Issued (OIJLIJ.i' 7 Authority Work Inspected bji: Permit Completion Date: Inspector's Signature Comments: Note: DriveWay approach must be constructed per Cityof La QUir tev - 6 2 dA rev tMjr/irEFJT 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'ci '1 kqe&.ik 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. 11i. i understand a frequent' practice of unlicensed persons is to hove 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. e92. 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. 00 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 flied in his br her. name instead of my own. [U4. I understand Contractors are required bylaw to be licensed and bonded in California and to list their license numbers on permits and contracts. V0.5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the totaivalue 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 ious financial risk. 4-7. 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. IJ8. 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.cc.gov for more information aout licensed contractors. -M 9. 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 con stryçtipg,1ctivify,at thefoLlowgaddres d'J 10. 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 1 ,ncr-Builders as well as employers. 1JiI ii. 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 on 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 tothe agency responsible for issuing the permit. Note: A copy of 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. Signature of property owner: ________________________________ Date: 7 78495 Colle Tampico La Quinta, CA 92253 • 760.777.7000 C. 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 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 Locafion or Address: -. - S S Name of Authorized Agent: . . Tel No. Address of Authorized Agent: . . I declare under penalty of perjury that I am the property owner for the Qddress listed above and I personally fitted 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:. .. .Dote: ri S . , S - 7 :5 tFI1i. Lo Quint 92253 7777.70I00