DRVA2019-0003Qa(&l 4
CEM.JJwDESERT - -
DRIVEWAY APPROACH
PUBLIC WORKS CONSTRUCTION
V/
[J eb Fi ce
FEB 072019 LL)
CITY OF LA QUINTA
DESIGN & DEVELOPMENT DEPARTMENT
For the construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewers, water mains and other like public work
improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS.
DATE: 2/7/2019
LOCATION OF CONSTRUCTION(Street address or Description): 53531 AVENIDA CARRANZA
PURPOSE OF CONSTRUCTION: DRIVEWAY APPROACH
DESCRIPTION OF CONSTRUCTION: DERRYBERRY/ DRIVEWAY APPROACH
DIMENSION OF INSTALLATION OR REMOVAL:
APPROXIMATE TIME WHEN WORK WILL BEGIN: 2/7/2019 TIME OF COMPLETION: 2/21/2019
ESTIMATED CONSTRUCTION COST: S1,200.00 (Including removal of all obstruction, materials, and debris, backfilling, compaction and
placing permanent resurfacing and/or replacing improvements)
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 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 regulations of the City of and
to pay for anyadditional replacement necessary as the result of this work.
,,,,
Signature of Applicant or Agent
ANTONIO CECENA(AUTHORIZED
AGENT) - 53531 AVENIDA CARRANZA LA QUINTA, CA 92253 (714)889-6092
Name of Applicant (please print) Business Address Telephone No.
OWNER BUILDER
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: $165.00
Policy Number
PERMIT NO: DRVA2019-0003
DATE ISSUED:?/7//9'
EXPIRATION DATE: ____
BY:f)
WORK INSPECTED BY:
PERMIT COMPLETION DATES:
51f the work is covered by a Subdivision Improvement Agreement,
Subdivider shall request final acceptance of improvements from the
City Council.
-- GEM ,Jdc DESERT -
DRIVEWAY APPROACH PERMIT APPLICATION
Applicant Information:
Applicant/Owner (p/ease print name here,k 72P'-'7 C)
Applicant Address:
,((_c4f"° i"' gdceaf(,
Number City State Zip Code
Address or Parcel No. of work location, if different f om a
5_3 /
Number Street
icant's address above:
1.4
City State Zip Code
Date: Li_?ji± Applicant's Phone No: C_7o) ftfr o
Applicant's Signature: .—.---'-
Approximate Start Date: /i_L!. Approximate Completion Date: _/Li1LiL
Contractor Information:
Address:
Number Street City State. Zip Code
Phone Number: _____ Contractors License Number:
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 $160 + $5 Technology Enhancement Fee = $165 Total Fee
Permit No. Expiration Date __/__l.
Permit Issued by: Date Issued
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
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GLM .f,L.e L) ES F RI
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
specifiedat____________________________________
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 J1. 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.
Rn
J2. 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.
el
LJ3. 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.
fSC4. I understand Contractors are required by law to be licensed and bonded in California
and to list their license .numers on permits and contracts.
l".-understan
.
d 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
(S500), including labor and materials, I may be considered an "employer" under state and
federal law.
T]CT 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.
EfT 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.
Ef8. 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.
S. 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:
E110. 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.
r7f-11. 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. (j i 4ur)
Signature of property owner: - Date: Z-.- 7- /7 -
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 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 dut 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
p
''. •.,
TiAt 4 4 auML
P.O. Box 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
(760) 777-7012
FAX (760) 777-7011
PROPERTY OWNER'S PACKAGE
Disclosures & Forms for Owner-Builders Applying for Construction Permits
IMPORTANT! NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at
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 building 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 sign ify you understand or verify this information.
.j(). 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 beh'eld liable and subject to serious finahcialisk 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.
J2. I understand building permits are not required to be signed by property owners unless they are responsible for the
coitruction and are not hiring a licensed Contractor to assume this responsibility.
3. I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may protect
m,yelf from potential financial risk by hiring a licensed Contractor and having, the permit filed 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
pezfnits and contracts.
4ñ15• I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value
d!.iy construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer"
under state and federal law.
L!L6. I understand if I am considered an "employer" under state and federal law, I must register with the state and federal
goc.'ernment, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment
compensation for each "employee." I also understand my failure to abide by these laws, may subject me to serious financial
risk.
ALT I understand under California Contractors' State License Law, an Owner-Builder who builds single-family residential
sctures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed
subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed
under contract with a licensed general building Contractor.
. 0
..tta8. I understand as an Owner-Builder if I sell the property for which this permit is issued, I: eh'ld liable for any
fncial or personal injuries sustained by any subsequent owner(s) that result from any latnt:Oi$ttion defeëts in the
workmanship or materials.
Q9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue
etc,ice, 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 building permit applied for in my name, and understand that I am the
legally and financially responsible for proposed construction activijy at the following address:
A) 2-4-- Liz- d1/ cJ'71# eig -
LAC i. I agree that, as the party legally ad financially responsible for this proposed construction activity, I will abide by all
applicable laws and requirements that govern Owner-Builders as well as employers.
A64 2. 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 building permit can be issued, this form must be
the agency responsible for issuing the peri Note. A co;
other verification acceble tq theage,T is.mired to
owner's signature.
Signature of property owner
npleted and signed by the property owner and returned to
"T1 property owner's driver's license, form notarization, or
presented when the permit is issued to verify the property
Date: ?r L flc SQ/f
Note: The following Authorization Form is require6W6e 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: 53, '53/ ai. t9AAIZI- M
Name of Authorized Agent: I12) ti/i7 L &A11 Tel No 7Ia-9T9 _IO2Z-
Address of Authorized Agent: .,. 2. VA
I declare under penalty of perjury that I qn the prope owner for the address listed above and I personally filled out the above
information and certify its ccuracy. Not44' opy of t4e owner 'sjriver's license, form notarization, or other verification
acceptable to the agency is ,presented when thej(rmit is issued to verify the property owner's signature.
Property Owner's Signature: Date:
-
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DERRYBERRY
KEVIN GENE
13312 MARSHALL LN
TUSTIN, CA 92780
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