04-7142 (RER)BUILDING'& SAFETY DEPARTMENT
c ^� P.O.. Box:1.504 (760).777-7012
Oh
�8 4.9-51`CALLE TAMPICO - FAX {760j 7774011
6 LA_Q II`I;TA,? CALIFO Nln 92253 .INSPECTIO,N REQUESTS -(.760) 777-7153
BUILDING PEp
N 0 E 2004. �. WIT
CITY OF Lie QUINTS ;
I
Ap :hocffit Number 0 0714` �D'ate' 12/06/04
Property Address 530&5 KVIENPDA-OBREGON-
APN:774 044-_016'-4' 0'0000.0
Application description ''REMODEL-tRESIDENT IAL
Property Zoning . . . COVE RESIDENTIAL
Applicat'lon valuation . . . . r' 200.00
Owner Contractor
BILL & REBECCA MACSEMS GENERAL CONSTRUCTION MGMT,`INC
53-085 AVENIDA .OBREGON. P:O:'.BOX :11`675
LA.QUINTA CA 92253 PALK DESERT' 'CA 92255
(7;60.). 779-..0:477
WCC:STATE ,..FUND'
WC.:; 22:M 029026 10/01/05.
CSLB:.... 8;35775 04/30/06
CCC B
------ Structure- hf.ormation -20'000.'REMODEL -----
Construction-:.T'pe TYPE, V NON,;RATED
Occupancy Type DWELLG/LODGING%.LONG <=10
Flood Zone NON AO.. FLOOD, -ZONE
Other struct.info CODE EDITION 2001 CBC
'BEDROOMS,; 3..00
Permit BUILDING PERMIT
Additional desc
Permit Fee 207.0`0 Pl-ari Check 'Fee 134.55
Issue -Date, Valu -at_ ion`' 20000
Expiration Date 5/24/05 i
e'.
Qty Unit Charge Per- { Extension'
BASE .FEE ti 45.00
18.00. 9.0000 THOU, 'BLDG :2,;001-2.5,0,00 162.00
-----------------------------------------------------------------------------
Permit ELECT. ADD ALT REM ..._.;
Additional des c
Permit Fee 2-4.45 Plan Check 'Fe'e 6.11
,Issue Date Vali_uatiori 0
Expiration Date 5/24/0.5
Qty Unit -'Charge .Per Extension
BASE FEE 15.00
21.00 4500 EA ELEC DEVICE/FIXTURE >20 9.45
r. r°
---------------------------
---------- - -
Permit
-
--------------------------
Additional desc
Permit Fee 24.00 'r wPlari4-Check Fee 6.00
Issue Date ' ` Valtiation . . . . .0
_r
P.O. Box 1504 • VOICE (760) 777-7012
78-495 CALLE TAMPICO FAX ,(760) 777-7011
LA QUINTA, CALIFORNIA 92253 4INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number: 1514- -71'+A- Date:
Applicant:
Applicant's Mailing Address:
L/11 I
Architect or Engineer:
Architect or Engineer's Address:
Lic. No.:
BUILDING PERMIT DECLARATIONS
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury thatA
er provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals
�C de, and my Licen is in full force and effG
ense Class nse No. Z7 357.5
Plate 0 ractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exemptrol the Contractors' State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed
statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business
and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects
the applicant to a civil penalty of not more than five hundred dollars ($500).):
U I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044,
Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does the work
himself or herself or through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for the purpose of sale.).
U I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
the Contractors' State License Law.).
U I am exempt under Sec. , BA P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance
of the work for which this permit is issued.
.jtave and will maintain workers' compensate n insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is
issued. My workers' compensation ' rance carrier and policy number are:
artier• ST AT16 R ).w 4) olicy Number '.'-L R nes-1- 9 D'L (o
I certify that, in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California, and agree II, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall
sions.
forthwith comply with those provi'1
WARNING: FAILURE TO SECURE WORKER S ION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLAR 100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on this application.
1. Each person upon whose behalf this application is made, each person at whose request and for whose benefit work is performed under or pursuant to any permit
issued as a result of this application, the owner, and the applicant each agrees to, and shall, defend, indemnify and hold harmless the City of La Quinta, its
officers, agents and employees for any act or omission related to a work being performed under or following issuance of this permit.
2. Any permit issued as a result of this application becomes null and id if work is not commenced within 180 days from date of issuance of such permit, or
cessation of work for 180 days will subject permi to cancellation.
I certify that I have read this application and state that the ab information i rrect. I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives of this coun enter upo he above-mentioned property for inspection purposes.
Date 1 b ignature (Applicant or Agent):
.q t ! P
IP.
j�p '
Page 2
Application Number 04-0;00.0,714,2
Date 12/06/04.
Expiration Date. 5/2.4/05
Qty Unit Charge Per
Extension
SASE.. FEES
15.00
1.00 9.0000 EA -MECHrA'PPL REP/ALT,/ADD
9.00
Permit . . . . . . PLUMBING
Additional desc
Permit' Fee 54.00 ...-.-Pavan .Check
Fee
13.50
Issue Date Valuation
0
Expiration Date. 5/24/`0:5
Qty Unit'Charge Per
Extension
BASE .FEE
15.00
6.00 6'., 0000 'EA P`tg'.FIXTURE.
36.00
1.00 3.0000 -EA PLB'WATER INST/ALT/REP
3.00
Special, Notes and;Comments
$ 20000 INT REMODELII/24/04 8 :1.3 : 59: AM
j j ohnson
_. .
--------------------------
OtherFees ENERGY-REVI_EW FEE.
13.46
Fee summary Charged Paid Credited
Due
Permit:Fee Total 309.45'w'.60
.00
309.45
Plan Check Tbtal ` 160,.16: ..0:0
. 00
160.16
Other 'Fee .Tot:,al 13 :'46- . 00
.00
13.46
Grand Total 483.07. ..00
.00
483.07
t
r
A
I
X
B
/Vek.,/T0 owe 53 A Ale'1,1 L.
-t
C9 T t
f
C'V 0 . J—) - -'! � �'
City of La Quinta
Building aZ Safety Division
00or P.O. Box 1504,18-495 CAA Tampico
.1 - La Quints, G92253.- (760) 7714012.
Building Permit Application and Tracking Sheet
Perm it #
I _7��
Project Address:
A. P. Number-
Legal Description: �[Citv.
Contractor. 3ea'/
0%%-ncr*s Name: -L, L 4(
Address: _atL 'Aug-, n137Z��)
ST. Zip: L&
FTelcphone: I
Address:
Xprpjcc,t Description:
City. ST. Zip:
-7-1. 1 7-4.)
,Telephone,
zioe
State Lic. # J %J.City Lic. #:
1W
Arch., Engr., Designer.
Address: VW
City. ST.'Zip:
_Aa U&ACJ'
Telephone:
.. J.-iConstunuction
Type: Occupancy:
State Lic. #:
Project
Pro e
Project type (eircle one): New Add'n
type
Name of Contact Person:/Y ZL-i rulj
Sq. Ft.: 00
0 Stories: i
w Units:
Telephone # of Contact Person: L5514�qqQ2,414
stirnatcd.Valu.c of Project:.
APPLICANT: DO NOT WRITE BELOW THIS LINE
IV
Submittal
Req.'d
Ree'd
TRACKJNG
PERNIM FEES
C:)_
—Plan Stu
Plan Check submitted��(ttItem
_Awovnl
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss CalCL
Called Contact Person
Plan Check Balance
Energy Calcs.
Plans picked sip I
l I
Construction
Flood plain Plan
Plans resubmitted
I . 4lechanical
Grading plan
2" Review, realy.for correcV.'nslissue
Eletin"cal
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up. 71VAV .0/\, "C -•3r—
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
Review, ready for correctionslissue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks- Appr
Date of permit issue
School Fees
Total Permit Fees
r
A
I
X
B
/Vek.,/T0 owe 53 A Ale'1,1 L.
-t
C9 T t
f
C'V 0 . J—) - -'! � �'