11-0066 (PLBG)P.O. BOX 1504
78-495 CALL E TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
11-D0000066
Property Address:
-80496 RIVIERA
APN:
762-200-034- -.
Application description:
PLUMBING
Property ZOnina:
LQW "DENSITY RE$.IDENTIAL
Application valuation:
500
Td4t . 4 4Q"
ApAlicant: Architect or Engineers
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
---------------------------------------------------
LICENSED CONTRACT 'S ECLARATION
I hereby affirm under penalty of perjury at I am licensed under rovi ons of Chapter 9 (commencing with
Section 7000) of Division 3 of the Busin s and Professionals C de; nd my License is in full force and effect.
License Class: 810 729-53 CLice a o.: 656128
Contractof.
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's 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 Contractor's 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).:
(_ I 1, 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 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.).
(_ 1 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project ISec. .
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.).
( 1 I am exempt under Sec. , B.&P.C. for this reason
Date:
Owner
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:
LQPERAIIT
Owner:
KVISTAD CLARK K
19102 94TH AVE WEST
EDMONDS, WA 98020
Contractor:
TESERRA
P.O. BOX 1280
COACHELLA, CA 92236
(760)398-9222
Lic. No.: 656128
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 1/19/11
------------------
WORKER'S 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.
I have and will maintain workers' compensation 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
insurance carrier and policy number are:
Carrier EVEREST NATL IN Policy Number 7600006481111
_ I certifythat, in the pert ante. of the work for which this permit is issued, I shall not employ any
- person in any manner as to be ome subject to the workers'.compensation laws of California,
and agree that, if I shot beco subject t he workers' compensation provisions of Section
ZOf the Labor Code; I hall rthwith mply with those provisions.11
Date: I
_.37'
�pplicant:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($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.
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 the work being .
performed under or following issuance of thispermit. .
2. Any permit issued as a result of this application becomes null and void if work is not commenced
within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject
• permit to cancellation. -
I certify that I have read this application and state that thea ve infor tion is correct. I agree to comply with all
city and county ordinances and state laws relating to building nstruc n, and hereby authorize representatives
of this/nly,en upon the above-mentioned property fors i pecti n purposes.
Date:./� Signature (Applicant or AgenO�
C,.
Application Number . . . . . '11-00000066
Permit . . . . PLUMBING
Additional desc .
Permit Fee. 18.00 Plan
Check Fee
4.50
Issue Date . . . . Valuation
0
Expiration Date 7/18/11
Qty . Unit Charge Per
Extension
BASE FEE
15.00
1.00 3.0000 EA PLB GAS PIPE 1-4
OUTLETS
3.00
----------------------------------------------------------------------------
Special Notes and Comments
42 LN FT X 1 1/2" GAS LINE & 22 LN FT OF
3/4 CONDUIT PER APPROVED PLANS & A.J.
Other Fees BLDG STDS ADMIN
(SB1473)
1.00
Fee summary Charged Paid
------------------------------
Credited
----------
Due
-----------------
Permit Fee Total 18.00 .00
.00
18.00
Plan Check Total 4.50 .00
.00
4.50
Other Fee Total_ 1.00 .00
.00
1.00
Grand Total •.23.50• .00
.00
23.50
LQPERM[T
NOISN3VYla
OSE 8I%'",laNSD U—G9%IS d . MMULIM
N0530 I"rLD3LlH3VV NOISN31MI0 HOlH31NI
a. i,
U*580 OPRd
ouqnb 4n Vm VW
oa&wppMpgsMW
.. I,
Bin #
City of La nulntd
�C
Building 8L Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking.Sheet
Permit #
Project Address:
Owner's Name: I `
A. P. Number:
Address: q d I S
Legal Description:
City, ST, Zip:
ZS'
Contractor:
Telephone:
h one:
Address:O V J C
Project Description:-
City, ST, Zip:i
U CA-q7 Z3 .6
Z LF_ OF/f 2 6o -_j L1.,V
ele h one ' 0 9 2
X0 2 Z
kTP
2 2 0 3
L_ � N'V
�o T
�
State Lie. # : 5 Z g
City Lie. #:
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone: hone:
Construction T e: 0= cu ane
Type: - P Y
State Lie. #•
Project Add'rAlter Repair air
type (circle one):• New Demo
Name of Contact Person:.
Sq. Ft.:
#Stories:
# Units:
Telephone # of Contact Person: (, o Z5 o -Z j 9
Estimated Value of Project:v Q Q . �
APPLICANT: DO NOT WRITE BELOW THIS LINE .
#
Submittal
Req'd
Recd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Cafes.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Title 24 Cafes.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2"" Review, ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Y
Total Permit Fees