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DRVA2018-0032wmage below for Fina e Re Codes r — —cEMqthDEsEwr -- DRIVEWAY APPROACH 11 11 DEC 172018 PUBLIC WORKS CONSTRUCTION CRONE N'r For the construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewers~my n§ 0N rks improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS. DATE: 12 /17/2018 LOCATION OF CONSTRUCTION(Street address or Description): 53521 AVENIDA VELASCO PURPOSE OF CONSTRUCTION: DESCRIPTION OF CONSTRUCTION: SPRUEILL / DRIVEWAY APPROACH DIMENSION OF INSTALLATION OR REMOVAL: APPROXIMATE TIME WHEN WORK WILL BEGIN: TIME OF COMPLETION: ESTIMATED CONSTRUCTION COST: (Including removal of all obstruction, materials, and debris, backfilling, compaction and placing permanent resurfacing and/or replacing improvements) COMMENTS: SECOND DRIVEWAY APPROACH ON VELASCO APPROVED PER PLANNING AND PUBLIC WORKS 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 atç 0) 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 regulations of the City of and to pay for any additional replacement necessary as the result of this work. Signature of Applicant or Agent NOELLE SPRUEILL Name of Applicant (please print) OWNER BUILDER Name of Contractor and Job Foreman Contractor's License No. Applicant's Insurance 53521 AVENIDA VELASCO LA QUINTA, CA 92253 (760)899-3746 Business Address Telephone No. Business Address Telephone No. City Business License No. Policy Number Finance Revenue Code PERMIT INSPECTION DRIVEWAY RESIDENTIAL $160.00 TECHNOLOGY ENHANCEMENT FEE $5.00 TOTAL: $165.00 PERMIT NO: DRVA2018-0032 DATE ISSUEMZ WOM~.`, EXPIRATION DATE: /7 111 BY WORK INSPECTED BY*: *If the work is covered by a Subdivision Improvement Agreement, Subdivider shall request final acceptance of improvements from the City Council. -- GEM of;be DESERT - DRIVEWAY APPROACH PERMIT APPLICATION Applicant Information: Applicä nt/Owner (p/ease print name here,k i2tJ/e Sig P-Z4 r r I Applicant Address: 53P ç / _,7h?/ 4/&s- 4 iM4 72S3 Number Street City State Zip Code Address or Parcel No. of work loáation, if different from applicant's address above: Number Street City State Zip Code Date: /2jIZiLf' Applicant's Phone No: (744') '-937z1A Applicant's Signature:T7'z_-t Approximate Start Date: Approximate Completion Date: Contractor Information: Address: Oc*jet 6.414W - Number Street City State Zip Code Phone Number: _____ Contractors License Number: City Business License Number: Geheral Liability Insurance Company: Policy No. Request for Inspection - Please call (760) 777-7097 before 1:30pm to request an inspection at /east 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 $160 + $5 Technology Enhancement Fee = $165 Total Fee Permit No. fl'-0031 Expiration Date Permit Issued by: Date Issued ...4JLLiiL Signature of Administrative Authority Work Inspected by: Permit Completion Date: Inspector's Signature Comments: Note: Driveway approach must be constructed per City of La Quinta Standard #221 REV: 11/27/2018 ta QaLq rev - ccxi .f,,,.. i,sr - 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 Azle,,it vwce~ ting seU e la _r s the builder of the driveway improvements Lspecifiedac.2/ C3 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. • 1. I unde rstand 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. P3. 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. I understand Contractors are required by law to be licensed and bonded in California and 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 an "employer" under state and federal law. i understand if I am considered an "employer" under state and federal law, I must tfegister 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. 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 remployer" 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 followina address: URId. 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. p11. 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:7Z— Date: 78-495 Calle 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 pfoperty 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:e,) Name Name of Authorized Agent:4ñz ,4 /1 Tel N74.) —3 '4( Address of Authorized Agent: 44 r 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 calle Tampico La Quinta, CA 92253 760.777.7000 w1 I 1% $ b4k - "'~, % NJ