BMCH2016-0182Applicant:
ANTHEM MECHANICAL
53-800 POLK STREET
COACHELLA, CA.92236.
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING PERMIT
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter
9 (commencing with Section 70001 of Division 3 of the Business and Professions Code,
and my License is in full force and effect.
License Class: A. B. C20 License No.: 1001659
Date
Contractor:
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).:
( ) 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.).
(� 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.).
(� 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
Lender's Address
VOICE (760) 777-7125
FAX (760)"777-7011
INSPECTIONS (760) 777-7153
Date: 6/23/2016
Owner:
KC DESERT VENTURES
6191 AIRPORT WAY NO 201
KELOWNA BC CANADA V1V, S2 92253
Contractor:
ANTHEM MECHANICAL
53-800 POLK STREET
.. • - COAC+iELLA, CA 92236
(760)469-2525
LIC. No.: 1001659
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:- Policy Number: _
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 that, if I should become subject to the
workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with those provisions.
Date: Applicant:
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 Building Official 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 this permit.
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 the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
Date: Signature (Applicant or Agent):
78-495 CALLE TAMPICO
LA.QUINTA, CALIFORNIA 92253
r
Application Number:
BMCH2O16-0182
Property Address:
81375 NATIONAL DR
APN:
767570001
Application Description:
HVAC CHANGE OUT
Property Zoning:
Application Valuation:
$7,000.00
Applicant:
ANTHEM MECHANICAL
53-800 POLK STREET
COACHELLA, CA.92236.
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING PERMIT
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter
9 (commencing with Section 70001 of Division 3 of the Business and Professions Code,
and my License is in full force and effect.
License Class: A. B. C20 License No.: 1001659
Date
Contractor:
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).:
( ) 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.).
(� 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.).
(� 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
Lender's Address
VOICE (760) 777-7125
FAX (760)"777-7011
INSPECTIONS (760) 777-7153
Date: 6/23/2016
Owner:
KC DESERT VENTURES
6191 AIRPORT WAY NO 201
KELOWNA BC CANADA V1V, S2 92253
Contractor:
ANTHEM MECHANICAL
53-800 POLK STREET
.. • - COAC+iELLA, CA 92236
(760)469-2525
LIC. No.: 1001659
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:- Policy Number: _
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 that, if I should become subject to the
workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with those provisions.
Date: Applicant:
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 Building Official 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 this permit.
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 the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
Date: Signature (Applicant or Agent):
FINANCIAL •RON
"DESCRIP,TION .'".ACCOIINTt, QTY" AMOUNT��";� PAID `,?.r PAID DATE
BSAS SB1473 FEE 101-0000-20306 0 $1.00 $1.00 5/26/16
PAID'BY, " :*: +' t.METHOD. "'RECEIPT# CHECK# ;� CLTD BY
Liliana Luna CREDIT WEB820 2016052616431428914 ECON
Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00 •$1.00
DESCRIPTION.r
" 'A: OUNTCC.':.
QTY
..AMOUNT';
PAID
PAID DATE,
HVAC CHANGEOUT - SPLIT -SYSTEM
101-0000-42402
0
$72.52
$72.52
5/26/16
` c PAID BY k"'a
METHOD ' r
-:RECEIPT #
CHECK # '
CLTD. BY'-
Liliana Luna
CREDIT <
WEB820
2016052616431428
ECON
_
914
r4 •4DESCRIPTION _
..R, ACCOUNTS
{wQTYa
. `a AMOUNT
PAID"
PAID DATE
„• �'?
HVAC CHANGEOUT - SPLIT -SYSTEM PC
101-0000-42600
0
$36.26
$36.26
5/26/16
PAID BY
METHODS'•¢.
ECEIPT #'
'CHECK # '
CLTD BY
Liliana Luna
CREDIT
WEB820 '
2016052616431428
ECON
914
Total Paid for CHANGEOUT: $108.78 $108.78
DESCRIPTION ^;
�� ACCOUNT
gTY
AMOUNT
*' PAID
PAID DATE
i
Credit Card Fee .
101-0000-43505
0
$4.44
$4.44
5/26/16
s <
t; •: PAID -BY „
` <� METHOD'
��:RECEIPT #� a""�
by CHECK #
CLTD BY
Liliana Luna
CREDIT
WEB820
2016052616431428
ECON
914
Total Paid for Credit Card Fee: $4.44 $4.44
f, r DESCRIPTION ., w'
_ ` ACCOUNT
QTY
'AMOUNTS ,�
PAID s,
PAID DATE
PERMIT ISSUANCE
101-0000-42404
0
$91.85
$91.85
5/26/16,
t PAID BY-,,, r
METHOD `,
.; RECEIPT #�
CHECK #
CLTD BY
Liliana Luna
CREDIT
WEB820
2016052616431428914
ECON
-
Total Paid for PERMIT ISSUANCE: $91.85 $91.85
TOTALS:0.$206.07
Description: HVAC CHANGE OUT
_
Type: MECHANICAL -HVAC
Subtype:
Status: ISSUED
Applied: 5/26/2016 ECON
CHANGEOUT (WEB)
-
Approved: 5/26/2016 ECON
Parcel No: 767570001 Site Address: 81375 NATIONAL DR LA QUINTA,CA 92253
Subdivision: TR 29657
Block:.
-Lot: 32
Issued: 5/26/2016 ECON
Lot Sq Ft: 0
Building Sq Ft: 0
Zoning:
Finaled:
Valuation: $7,000.00
Occupancy Type:
Construction Type:
Expired: 11/22/2016 ECON
No. Buildings: 0
No. Stories: 0
No. Unites:,0
Details: .
Appiiea to Approvea f
Approved to Issued ""
ADD
,.CONDITIONS
I I 201 I CANADA V1V
INFORMATION r '
Printed: Thursday, June 23, 2016 8:41:36 AM 1 of 3
• � WSYS TEti1S
DESCRIPTION
''
DATE
e: ACCOUNT ,
QTY
:AMOUNT
PAID
PAID
'RECEIPT:#
CHECK #.
METHOD
a.
PAID BY
Y•�
I
201605261
BSAS SB1473 FEE
101-0000-20306
0
$1.00
$1.00
5/26/16
WEB820
643142891
CREDIT
Liliana Luna
ECON
4
Total Paid for BUILDING STANDARDS ADMINISTRATION
$1.00 $1.00
BSA:
HVAC CHANGEOUT -
201605261
101-0000-42402
0
$72.52
$72.52
S/26/16
WEB820
643142891
CREDIT
Liliana Luna
ECON
SPLIT -SYSTEM
4
HVACCHANGEOUT-
201605261
101-0000-42600
0
$36.26
$36.26
5/26/16
WEB820
643142891
CREDIT
Liliana Luna
ECON
SPLIT -SYSTEM PC
4,
Total Paid for CHANGEOUT: $108.78 $108.78
201605261
Credit Card Fee
101-0000-43505
0,
$4.44
$4.44
5/26/16
WEB820
643142891
CREDIT
Liliana Luna
ECON
4'
Total Paid for Credit Card Fee: $4.44 $4.44 .
201605261
PERMIT ISSUANCE
101-0000-424040•
$91.85
$91.85
5/26/16
WEB820
643142891
CREDIT
Liliana Luna .
ECON
Total Paid for PERMIT ISSUANCE: $91.85 $91.85
$206.07 $206.07
INSPECTIONSTOTALS:
,.,
ARE'
_. ......., . ...... ... _....... NT PROJECTS
Printed: Thursday, lune 23, 2016 8:41:36 AM 2 of 3
sysTEMS