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BMCH2016-026778-495 CALLE TAM'PICO LA QUINTA, CALIFORNIA 92253 Application Number: Property Address: APN: Application Description Property Zoning: Application Valuation: Applicant: ANTHEM MECHANICAL 53-800 POLK STREET COACHELLA, CA 92236 BMCH2O16-0267 54105 EISENHOWER DR 774215018 HVAC CHANGE OUT $6,651.00 DESIGN & 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 7000) 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. 7&31.5, 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, 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 Na Lender's Add VOICE (760) 777-7125 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: .8/2/2016 Owner: SANDY STAKE 54105 Eisenhower Dr. La Quinta, CA 92253 Contractor: ANTHEM MECHANICAL 53-800 POLK STREET COACHELLA, CA 92236 (760)895-2621 Llc. 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 polity number are: Carrier: STATE COMPENSATION INSURANCE FUND Policy Number: 9154382 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 CINE 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'SFEES. 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): r Date: 8/2/2016 Application Number: BMCH2016=0267, Owner: Property Address: 54105 EISENHOWER DR SANDY STAKE APN: 774215018 54105 Eisenhower Dr. Application Description: HVAC CHANGE OUT La Quinta, CA 92253 Property Zoning: Application Valuation: $6,651.00 Applicant: Contractor: ANTHEM MECHANICAL ANTHEM MECHANICAL 53-800 POLK STREET 53-800 POLK STREET COACHELLA, CA 92236 COACHELLA, CA 92236 (760)895-2621 --------------------------------------------------------------------------------------------- LIC. No.: 1001659 Detail: r FINANCIAL INFORMATION DESCRIPTION ACCOUNTQTY AMOUNT . BSAS SB1473 FEE 101-0000-20306 0 $1.00 Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00 DESCRIPTION ACCOUNT CITY AMOUNT HVAC CHANGEOUT - PACKAGED UNIT 101-0000-42402 0 $36.26. DESCRIPTION ACCOUNT QTY AMOUNT HVAC CHANGEOUT - PACKAGED UNIT PC 101-0000-42600 0 $24.17 Total Paid for CHANGEOUT: $60.43 DESCRIPTION ACCOUNT QTY AMOUNT Credit Card Fee 101-0000-43505 0 $3.37 Total Paid for Credit Card Fee: $3.37 DESCRIPTION ACCOUNTQTY AMOUNT PERMIT ISSUANCE 101-0000-42404 0 $91.85 Total Paid for PERMIT ISSUANCE: $91.85 r Description: HVAC CHANGE OUT CONDITIONS Type: MECHANICAL - HVAC Subtype: Status: ISSUED Applied: 7/20/2016 ECON CHANGEOUT (WEB) FAX EMAIL Approved: 7/20/2016 ECON Parcel No: 774215018 Site Address: 54105 EISENHOWER DR LA QUINTA,CA 92253 Subdivision: SANTA CARMELITA AT VALE LA QUINTA Block: 298 Lot: 6 Issued: 7/20/2016 ECON UNIT 27 ANTHEM MECHANICAL 53-800 POLK STREET COACHELLA Lot Scl Ft: 0 Building Sq Ft: 0 Zoning: Finaled: Valuation: $6,651.00 Occupancy Type: Construction Type: Expired: 1/16/2017 ECON No. Buildings: 0 No. Stories: 0 No. Unites: 0 (760)895-2621 Details: INFO@ANTHEMMECH ANICAL.COM OWNER SANDY STAKE Applied to Approved Approved to Issued CHRONOLOGY CONDITIONS ZIP PHONE FAX EMAIL NAME TYPE NAME ADDRES Sl CONTACTS CITY STATE APPLICANT ANTHEM MECHANICAL 53-800 POLK STREET COACHELLA CA 92236 (760)895-2621 INFO@ANTHEMMECH ANICAL.COM CONTRACTOR ANTHEM MECHANICAL 53-800 POLK STREET COACHELLA CA 92236 (760)895-2621 INFO@ANTHEMMECH ANICAL.COM OWNER SANDY STAKE 54105 Eisenhower Dr. La Quinta CA 92253 1 (760)895-2621 Printed: Tuesday, August 02, 2016 7:55:22 AM 1 of 3 SYS7[AAS INSPECTIONS Printed: Tuesday, August 02, 2016 7:55:22 AM 2 of 3 WS )TSYSTr' CLTD -] DESCRIPTION ACCOUNT QTY AMOUNT. PAID PAID DATE RECEIPT # CHECK # METHOD PAID BY BY 201607201 BSA$ SB1473 FEE 101-0000-203060 $1.00 $1.00 7/20/16 WEB920 916491787 CREDIT Liliana Luna ECON 9 Total Paid for BUILDING STANDARDS ADMINISTRATION $1.00 $1.00 BSA: 201607201 HVAC CHANGEOUT - 101-0000-42402 0 $36.26 $36.26 7/20/16 WEB920 916491787 CREDIT Liliana Luna ECON PACKAGER UNIT 9 201607201 HVAC CHANGEOUT - 101-0000-42600 0 $24.17 $24.17 7/20/16 WEB920 916491787 CREDIT Liliana Luna ECON PACKAGED UNIT PC 9 Total Paid for CHANGEOUT: $60.43 $60.43 Credit Card Fee 101-0000-43505 0 $3.37. $3.37 7/20/16 WEB920 12016072011. 916491787 CREDIT Liliana Luna ECON 9 Total Paid for Credit Card Fee: $3.37 $3.37 oil PERMIT ISSUANCE 101-0000-42404 0 $91.85 $91.85 7/20/16 WEB920 916491787 CREDIT Liliana Luna I ECON 9' Total Paid for PERMIT ISSUANCE: $91.85 $91.85 TOTALS: INSPECTIONS Printed: Tuesday, August 02, 2016 7:55:22 AM 2 of 3 WS )TSYSTr' Permit Details PERMIT NUMBER 0V6=041 01�k BMEH-21267City of La Quinta Attachment Type CREATED OWNER DESCRIPTION PATHNAME SUBDIR ETRAKIT ENABLED .DOC 7/20/2016 EtrakitContractor CF1R Stake, Sandra CF1R.pdf 1 J Printed: Tuesday, August 02, 2016 7:55:22 AM 3 of 3 C SYS7f:MS