DRVA2018-0025'4
See below ftu Finance Re eCodes
- GEM ,fthcDESERT --
DRIVEWAY APPROACH OCT 302018
PUBLIC WORKS CONSTRUCTION
CITY OF LA QUINTA
For the construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewersDj(
improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS.
DATE: 10/30/2018
LOCATION OF CONSTRUCTION(Stréet address or Description): 78775 AVENIDA ULTIMO
PURPOSE OF CONSTRUCTION: DRIVEWAY APPROACH PER CITY STANDARD 221
DESCRIPTION OF CONSTRUCTION: ALONZO / DRIVEWAY APPROACH
DIMENSION OF INSTALLATION OR REMOVAL:
APPROXIMATE TIME WHEN WORK WILL BEGIN: 10/31/2018 TIME OF COMPLETION: 11/8/2018
ESTIMATED CONSTRUCTION COST: (Including removal of all obstruction, materials, and debris, backfilling, compaction and placing
permanent resurfacing and/or replacing improvements)
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 all
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) 777-7097. 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 and of and
pay for any additional replacement necessary as the result of this work.
- .-. ---- ----
LT CONSTRUCTION 44531 ROUND TABLE STREET INDlO, CA 92201 (760)485-7587
Name of Applicant (please print) Business Address 0 Telephone No.
OWNER BUILDER 0
Name of Contractor and Job Foreman Business Address , •
Telephone No.
Contractor's License No. City Business License No.
Applicant's Insurance Company
Finance Revenue Code
PERMIT INSPECTION
DRIVEWAY RESIDENTIAL $160.00
TECHNOLOGY ENHANCEMENT FEE $5.00
TOTAL: $0.00
Policy Number
PERMIT NO: DRVA2018-0025
DATE ISSUED:
EXPIRATION DATE: Jf2!bfi (.
BY:J
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.
rParcel No. of work location, if different from applicant's address above:
Street City State Zip Code
Address
15 1
Number
,1 •
- CE f&DESKT -
DRIVEWAY APPROACH PERMIT APPLICATION
Applicant Information:
Applicant/Owner (please pijot name here): \b(V7 ci
Applicant Address: L\Ld\S \/ J(JsJ(
Number Street City State 2pode
Date: I'D /_'A_/ Appli ant's Phone No: ("c) -RC'j
Applicant's Signature: 6-CA
—
Approximate Start Date: /0/.L//fI7 Approximate Completion Date:
Contractor Information:
Address: 5'?'c3/ . c 220(
Number Street City State Zip Code
Phone Number: LQ) 9cY5 .4— Contractors License Number: 3
City Business License Number: 5V? ?-
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) 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.
Permit Issued by:
Work Inspected by:
Comments:
Expiration Date II
Signature of Administrative Authority
Inspector's Signature
Date Issued / I
Permit Completion Date: ......j_I
.Note: Driveway approach must be constructed per City of La Quinta Standard #221
Permit application submittal requirements:
1. Application completely filled out with the following items attached
a. Ensure there's a City Business License # on application
2. Current. Certificate of Liability Insurance
City of La Quinta as additional insured with endorsement if work is being done in the
public right of way
S
3. Traffic Control-Plan if there are lanes on public streets being closed
Traffic Control plan must be stamped by a Civil or Traffic Engineer or;
Applicable traffic control plan from 2012 WATCH Manual or 2012 California MUTCD.
4. Bonds or cash deposits may be required for grading, off-site improvements, and/or dust control
LI
tcv* Qa1w rev
- GM ',f:lv DESERT -
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_i11 f\'Jmài k'cyrn kj4 uVVr(,&, (J
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.
On 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.
Yt
I understand as an "Owner-Builder" I am the responsible pa rty of record on the
t. 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.
I understand Contractors are required by law to be licensed and bonded in California
rind to list their license numbers on permits and contracts.
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 on "employer" under state and
federal low.
6. I understand if! 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.
0- I understand as an Owner-Builder if! 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 a%.
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.
09. 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 t he following address:
Wk0. I agree that, as the pa rty legally and fi nancially responsible for this proposed
construction activity, I will abide by all applicable laws and requirements that govern
Owner-Builders as well as employers.
011. 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 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:
73-495 Cal(e Tampico La Quinta, CA 92253 760.777.7000
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 Location 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: CZ 6. Date: (J I
78-495 calle Tampico : La Quinta, CA 92253 ' 760.777.7000
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