DRVA2017-0035Z
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DRIVEWAY APPROACH S ______1
PUBLIC WORKS CONSTRUCTION jVDSWWEWDEP 0 n o
For the construction of public or private curbs, driveways, pavements, sidewalks, parking lots; sewers, water mains and other like public wor
improvements in connection with MINOR IMPROVEMENTS and APPROVEDSUBDIVISIONS. S
DATE: 12/29/2017
LOCATION OF CONSTRUCTION(Street address or Description): 51199 AVENIDA HERRERA
PURPOSE OF CONSTRUCTION: NEW APPROACH
DESCRIPTION OF CONSTRUCTION: DUCE DRIVEWAY APPROACH
DIMENSION OF INSTALLATION OR REMOVAL:
APPROXIMATE TIME WHEN WORK WILL BEGIN: 12/28/2017 TIME OF.COMPLETION: 1/2/2018
ESTIMATED CONSTRUCTION COST: $500.00 (Including, removal of all obstruction, materials, and debris, backfilling; compaction and
placing permanent resurfacing and/or replacing improvement) . . .
COMMENTS:
In consideration of the granting of this permit, the applicant hereby agrees to:..
Indemnify, defend and save the City, its authorized agents, officers, representatives and employees, harmless from and against any and al
penalties, liabilities or. loss resulting from claims or court action and arising out of any accident, loss or damage-to persons or property
happening or occurring as a proximate result of any work undertaken under the permit granted pursuant to this application.
Notify the Administrative Authority at least twenty-four (24) hours in advance of the time when work will be started at (760) 77777097. To
submit an inspection request, leave a message on the Inspection Request Hotline at (760) 777-7097 prior to 1:30 P.M. at least twenty-four
(24) hours prior to the anticipated inspection. .
Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules
to pay for any additional replacement necessary as the result of this work.
OJEDA POOL & SPA 52-815 AVENDA MARTINEZ LA QUINTA, CA 92253
Name of Applicant (please print) Business Address
OWNER BUILDER
Name of Contractor and Job Foreman Business Address
regulations of the City of and
re plicant or Agent
(760)564-6274
Telephone No.
Telephone No.'
Contractor's License No. . City Business License No.
Applicant's Insurance Company
. . . Policy Number . . .
Finance Revenue Code
PERMIT INSPECTION
DRIVEWAY RESIDENTIAL . . .
$156.00
TECHNOLOGY ENHANCEMENT FEE . .$S.
TOTAL: $0.00
PERMIT NO: DRVA2017-0035.
DATE ISSUEDj// / 7
EXPI4 DATE: !qi1g
WORK INSPECTED BY*:
PERMIT COMPLETION DATE: •
*If the work is covered by a Subdivision Improvement Agreement,
Subdivider shall request final acceptance of improvements from the
City Council. .
City State Zip Code
Contractors License Number: 7 762___
H..•.
42uid
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DRIVEWAY APPROACH PERMIT APPLICATION
Applicant Information:
Applicant/Owner (please print name.here): c:9q
Applicant Address: (5/ /9? iØ't' ói . ,1A'67Z1 z1-•t;24
Number Street
*4 7736C9 Address or Parcel ho. of work location. if d
City
rent from aDalicant's address
:e ZZJ3
State Zip Code
Number . -Street '
.
' (it ' f State Zip Code
Date: '/'/7Appli t's Phone No: (7O) 27S.
Applicant's Signat re: 1 ooi
Approximate Sta Date:' iiL2pproximate Completion Date: O/,O2726/7
Contractor Information:
Address: 5ZiS 4'1
Number Street
Phone Number:
City Business License Number: 6A
General Liability Insurance Company:" Policy No. 6i
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 N o. ExpirationDate
3 . .
Permit Issued by: . . Date Issued .
Signature of Administrative Authority
p
Work Inspected by: Permit Completio.n Date: __I._J
Inspector's Signature
Comments:
Note: Driveway approach must be constructed per City of La Quinta Standard #221
t P ey - Qa & ev
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PROPERTY OWNER'S, PACKAGE.
DiscLosures & Forms for Owner-Builders Applying for briveway PermIts
IMPORTANT! NOTICE TO PROPERTY OWNER
Der 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 bUi1dei of the d riveway irnprnients
specifiedt 51199 Au3iOA
We are providing you with an Owner-Builder Acknowledgment band 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 ogent of the
owner cannot execute this notice unless you, the property owner, Obthih 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
inform dtiOn.
h . 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 oil Owner-Builder,
may be held tidbLe 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 On Owner-Builder and am aware of the Lirriits of my insurOnce coverage for injuries to
Workers on my prOperty.
L!M 2. 1 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 respOrsibility.
E '3 I understand as an "Owner-Builder" I cm the responsible party of record on the
permit 1 understand that I may protect myself from potential financial risk by hiring a
licensed Contractor and:hovin the permit flied in:his br her.name instead-of my own.
UM
I understand Contractors are required by low.to, be.licensed and bonded in COliforni
and. to list their license numbers on permits Ondcontacts.
I undetand if I employ Or otherWLe engage any perbns, other than CaliforhiO'
licensed Contractors, and the total value of my construction is at Least five hundred dollars
($500), including labor and materials, I may be corisidered.dn"employer"under.state and
federat law.
to 6 I understand if I am considered an 'employer" rUhder state and federal Law, I must
register with the state and federaL government, withhold payroll taxes, provide Workers'
compensation disabltty ifisurance and contribute to unemployment compensation for
each "employee" I also understand my failure to qbide by these laws may subject me to
serious-financial risk.
IJ7. I uhderTstOnd as On Owher-Builder if sell the Oe6O6rtyf61rhich this permi t is isUed, I
may be held liable for any fihanciaL or personal injuries sUstdibed by any tubtquent..
owner(s) that result from any:ldtent construction defects in the workmanship or materials.
I1'. i. understand I may. obtain more information regarding>my obligations as .an
"employer" from: the InternqL Revenue. Service, the :United States Small Business
Administration, the Califonia Department Of Benefit Payments,, dnd,-
.
thi California Division
of Industrial Accidents I also understand I may contact the California Contractors' State
License BOord•(SLB) at 1-800-321-CSLB (2752) or www.cslb.ca.9ov for more. information
about Licensed contractors.
1J 9. I am.aware of and consent to v an Owner-Builder driveway permit aptie4 for in my
name, and understand that I am the party legally and financially responsible for proposed
construction activrt' at the followin9 address
10.. I agree that, as the party legally and finandatly responsible. for this proposed
construction activity, I will abide by all applicable laws and requirements that govern
Owner-Builders as well asernployers.
Is 11. I agree tO notify the issüèr of this fan-n 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 be unable to assistyou'with
any financial loss you may sustain as o result of a complaint Your only feinedy 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 individudi or firm is injured while
working onyour 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.
I.
Before a driveway perrñit can be issued, th farm must be completed and signed by
the property owner and returned td the agency responsible for issuing the permit.
Note A copy of property owner's driver's license or notarization, or other verification
acceptable to the agency is required to be pre nt9d when the permit is issued to verify'
the property owner's signature.- 4' /
Signature of property owr 121Z fhWl Date:____
—r-
78495 Caile Tampico ...............La Quinta. CA-92253 -. • 760.777.7000
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Name: ofAuthorizedAgent:
:Adth5sPfAuthQriZed Ager
t:95qO
Note The following Authorization Form is required to be completed by the propthty owner
only when designating an agent of the property owner to apply for a construction permit for
the Owner-Buildèr.
AUTHORIZATION OF AGENT TOACJON PROPERTVOWNER. BEHALF
Excluding the Notice to Property Ohér, theexécütion qf .-wh ich 1 understand is my
al person responsibility, I hereby authorize the following person(s) to act as my agent(s) to
apply for, sign, and fife the documents necessary to obtain an Owner-Builder Permit for my
project:
Scope óf:Consfruction Project (or Description of Work): CbuP
Project Location or Address L571/t'f 40'51'.4 /1/&Z41
I .decLäfe under .péñalty ofpeTrjclry "thdt F 0Th the poptyher foe the addrèss •(sted
11
above and I personaLly filled out the above information and certify its accurdcy Note A
copy of the owner's driver's license, form notarization other verification acceptable to the
agency is required to be presented when the per i is is ued to verify the property owner's
si'gndture.
Property Owner's SighotUre:
I'
Imam
78-495 Catte Tqmpico La QUinta,CA92253. 760,777.7000