PLBG (11-0518)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
4
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Application Number: ' 11-00000518 _ Owner:
Property Address: 77600 CALLS, MONTEREY DENNIS FREEMAN
APN: 774-052-02,9-12 -000000 51625 DESERT CLUB #201
Application description: PLUMBING LA QUINTA, CA 92253
Property Zoning: COVE RESIDENTIAL
Application valuation: 2000
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 5/18/11
LQPERMIT
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Contractor:
Applicant: Architect or Engineer:
TRI STAR CONTRACTIN Ia--1N
15501 LITTLE MORON ROAD A
DESERT HOT SPRING, i
(760)251-5454 yy�� q
Lic. No.: 909195 „ i`ty 18
'. ;•
2011
CITY OF -,77o-- QUINTA
LICENSED CONTRACTOR'S DECLARATION
WORKER'S COMPENSATION DECLARATION
?; 1 hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with
- I hereby affirm under penalty of perjury one of the following declarations:
Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect.
_ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided
.. .:' 'License Class: A License No.: 909195
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is ,
-,i ,. -
-
issued.
Date: Contractor: -
_ 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
OWNER -BUILDER DECLARATION
insurance carrier and policy number are:
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the
Carrier EVEREST NAT' L Policy Number 7600005937101
- following reason (Sec. 7031 .5, Business and Professions Code: Any city or county that requires a permit to
ertify that, in the performance of t e work for which this permit is issued, I shall not employ any
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the
person in any manner so as to come subject to the workers' compensation laws of California,
+' permit to file.a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State
�IChapter
and agree that, if I should c subject th rs' compensation provisions of Section
License Law 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code).or
3700 of the Labor Code, 11 rthwit co h hose provisions.
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).: -
�If`'
ate: scant:
•' (. 1 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
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL _
Contractors' State License Law does not apply to an owner of property who builds or improves thereon,
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
- and who does the work himself or herself through his or her own employees, provided that the
DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
improvements are not intended or offered for sale. If, however, the building or improvement is sold within
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
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.).
- APPLICANT ACKNOWLEDGEMENT
(_V_M I, as owner of the property, am exclusively contracting with licensed. contractors to construct the project (Sec.
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the '
7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of
conditions and restrictions set forth on this application.
property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed
1. Each person upon whose behalf this application is made, each person at whose request and for
•
pursuant to the Contractors' State License .1.
whose benefit work is performed under or pursuant to any permit issued as a result of this application,
(_) I am exempt under Sec. , B.&Pans f is reaso
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 anyact or omission related to the work being
!` / C �' I
ate: J 6 er: 1
performed under or following issuance of this permit. -
2. Any permit issued as a result of this application becomes null and void if work _is not commenced '
�_Am
within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject
CONSTRUCTION LENDING AGENCY
permit to cancellation.
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the
1 certify that I have read this application and state that the above ormation is orrect. I agree to comply with all
' work for which this permit is issued (Sec. 3097, Civ: C.1•
city and county ordinances and state laws relating to building. cruction, a he authorize representatives
•
of this county to enter upon the bove-mentioned property n action ur s
Lender's Name:
L
JPdfl.
_1 ( Si ature (Applicant or Agent):
Lender's Address: (�
LQPERMIT
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Application Number 11-00000518
Permit . . . PLUMBING SEWER
Additional desc .
Permit Fee 30.00
Plan Check Fee
.00
Issue Date
Valuation . . .
. 2000
Expiration Date 11/14/11
Qty Unit'Charge Per
Extension
BASE FEE
30.00
Special Notes and Comments
SEPTIC ABANDON, SEWER CONNECT. 2010_
CODES.
----------------------------------------------------------------------------
Other Fees BLDG STDS ADMIN (SB1473)
1.00 ,
Fee summary Charged Paid
Credited
Due
Permit Fee Total 30.00
.00 .00
30.00
Pian Check Total .00
.00 00
.00
Other Fee Total 1.00
.00 .00
1.00
Grand Total 31.00
.00 .00
31.00
LQPERMIT .. _.
Received From:-
Address:
,,fir c
Account No. Lot(s) Trac
ServiceAddmas - G.A. Code
O Meter(s) s
O Servlcs(s)
O Backflows)
O House Lateral(s)
O Detector Check(s) - - - - - -- —
O Mry
eterSurchae
SMe/anitation Capacity Charge (0 L
❑ WS.B.F.C.
O Temporary Construction Meter +
O Tum on Charge
❑ Uncollected Account - Name
O Inspection Fee - Tract -
Fee -
O Plan Check Fees Water I Sewer - .
Tract -
❑ Bond Payment - A.D. - Bond
Asamt
O Customer Deposit
❑ Other
f TOTAL
Remarks:
to:
Bin #
City of La Quints
-Building & Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
GJ �/
Project Address: �.1 (poo C (4l-l.F MO I,.) i�.(l fc
Owner's Name: ��a'pJt.S ��� J
A. P. Number:
Address: Sl b L-1: DeStAT C L.�Ig OR 44' Lo1
Legal Description:
Contractor:
City, ST, Zip: La &U , AJ -1-4
Telephone: .7 66' q''I
Address:
Project Description: S
City, ST, Zip:
Telephone:TI
State Lic. # :
City Lic. #;
Arch., Engr., Designer:
Address:
City., ST, Zip:
Telephone: #:s•�;s. Aw;;;; `. ':
•.x� F/nl):n'+jlNX.
;
State Lic: #::tom; %"<:#`<z <r:::?: i>:`'
:;•�.;;;,>„.;.;r,;:�,.:.;:;;.�k;
Name of Contact Person:
Construction Type: Occupancy:.
Project type (circle one): New . Add'n Alter Repair Demo
Sq. Ft.:
# Stories:
# Units:
Telephone # of Contact Person:
Estimated Value of Project: ,2 p p p.
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Req'd
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
Tide 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 correctionstissue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. App r
Date of permit Issue
School Fees
Total Permit Fees