BSPN2015-0023•r
is issued: My workers compensation. insurance carrier and polity number are:
OWNER -BUILDER DECLARATION
Carrier. Policy Number:
•
�� certifythat in the performance of the work for which this permit is issued, I
,
License Law for the f ollowing reason (Sec. 7031:51 Busrim and Professions Code: Any
shalPnot employany person in any manner, so as to become subject to the workers'
78-495 CALLE TAM PICO
Di�Cl/
any structure, prior to its issuance, also requires the applicant for the permit to file a
VOICE (760) 777-7125
signed statement that.he or she is licensed pursuant to the provisions of the
comply with those provisions.
Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division 3
FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253
COMMUNITY DEVELOPMENT DEPARTMENT INSPECTIONS
(760) 777-7153
BUILDING PERMIT
WARNING: FAILURE TO.SECURE.WORKERS';COMPENSATION COVERAGE IS UNLAWFUL,
0$5 0)1:,,,S
AND SHALL.SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
j; as owner of the property, or my employees with wages as their sole. '
ONE'HUNDRED THOUSAND DOLLARS ($100;000). IN ADDITION TO THE COST OF
Date: 6/24/2015
Application Number: BSPN201S-0023
(Sec. 7044, Business and Professions Code: The Contractors' State License Law does'not
Owner:
apply to an owner of property who builds or improves thereon, and who.does the work
Property Address: 52655 AVENIDA RUBIO
himself or herself through his or her own employees,'provided that the improvements,
JEFFREY HORGER
are not intended or offered for sale. If, however, the building.or improvement is sold
APN: 773282020
within one year of completion, the owner -builder will have, he burden "of"proving that ;
52655 AVENIDA RUBIO
^she did not build, or improve for the purpose of sale.),
Application Description: GAS TEST INSPECTION,TO CONVERT FROM PROPANE TO NATURAL GAS.
LA QUINTA, CA 92253
request and1or. whose benefit work is performed under or pursuant to any permit
Property Zoning:
issued as a:result of this application , the owner, and the applicant, each agrees to, and .
State License Law does not apply to an owner of property who builds or improves
Application Valuation: $950.00
employees for any act or omission related to the work being performed under or
W0 j6 on tractors' State License Law.).
following issuance of this permit.
{� am exempt under Sec: B.&P.C. for this reason
2. Any permit issued as a.result of this application becomes null and void if work is
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L
Applicant:Contractor.
'< o
JEFFREY. HORGER
o .
52655 AVENIDA RUBIO
m Q
O L�
LA QUINTA, CA 92253
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9
LIc. No.:
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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: License No.:
Date:
Contractor:
WORKER'S COMPENSATION DECLARATION
I hereby affirm underpenaltyof 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 3.700 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
Date,.(OC L - l S own` r&V-12l n! a L>L l e c I
�� CONSTRUCTION LENDING AGENCY I
I hereby affirm under penalty of perjury that there is a construction lending agency for c
the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's
Lender's
certify that l have read this application and state that the above information is correct.
agree to. comply with all cityand county ordinances and state laws relating to building
onstruction, and hereby authorize representatives of this city to enter upon the abs ve-
mentioned property for inspection purposes:
Dat �Y �� Signature(Applicant orAgeni).
is issued: My workers compensation. insurance carrier and polity number are:
OWNER -BUILDER DECLARATION
Carrier. Policy Number:
I hereby affirm under penalty of perjury that I am.exempt from the Contractor's State
�� certifythat in the performance of the work for which this permit is issued, I
,
License Law for the f ollowing reason (Sec. 7031:51 Busrim and Professions Code: Any
shalPnot employany person in any manner, so as to become subject to the workers'
city or county that requires a permit to construct, alter, improve, demolish, orrepair
compensation laws of California, and agree that, if I should become subject to the
any structure, prior to its issuance, also requires the applicant for the permit to file a
workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
signed statement that.he or she is licensed pursuant to the provisions of the
comply with those provisions.
Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division 3
'— �� " - I-�ra
of the Business.and Professions Code or that he or she is exempt therefrom and the
p
Date:--� Z—(� . Applicant: e
cant: ua� n a
basis for the alleged exemption. Any violation of Section 7031.5 by any appkant:for a .
permit subjects the applicant to a civil penalty of not more'than five hundred dollars
WARNING: FAILURE TO.SECURE.WORKERS';COMPENSATION COVERAGE IS UNLAWFUL,
0$5 0)1:,,,S
AND SHALL.SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
j; as owner of the property, or my employees with wages as their sole. '
ONE'HUNDRED THOUSAND DOLLARS ($100;000). IN ADDITION TO THE COST OF
compensation, will do the work, and the structure is not intended or offered for sale'.
COMPENSATION; DAMAGEIS AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,
(Sec. 7044, Business and Professions Code: The Contractors' State License Law does'not
'INTEREST, AND ATTORNEY'S FEES.
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,
APPLICANT,ACKNOWLEDGEMENT
are not intended or offered for sale. If, however, the building.or improvement is sold
IMPORTANT: Application is hereby made to the Building Official for a permit subject to
within one year of completion, the owner -builder will have, he burden "of"proving that ;
i :the'coriiiitions and restrictions set forth.on:this application.
^she did not build, or improve for the purpose of sale.),
1. EacFi personvpon whose behalf this application is made, each person at whose
(f'Ihe'
'I�as owner of the property, am exclusively contracting with licensed contractors
request and1or. whose benefit work is performed under or pursuant to any permit
et -construct the project. (Sec. 7044, Business and Professions Code: The Contractors'
issued as a:result of this application , the owner, and the applicant, each agrees to, and .
State License Law does not apply to an owner of property who builds or improves
shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and
thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
employees for any act or omission related to the work being performed under or
W0 j6 on tractors' State License Law.).
following issuance of this permit.
{� am exempt under Sec: B.&P.C. for this reason
2. Any permit issued as a.result of this application becomes null and void if work is
i/
not commenced within 180 days from date of issuance of such permit, or cessation of
work for 180 days.will subject permit to cancellation.
Date,.(OC L - l S own` r&V-12l n! a L>L l e c I
�� CONSTRUCTION LENDING AGENCY I
I hereby affirm under penalty of perjury that there is a construction lending agency for c
the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's
Lender's
certify that l have read this application and state that the above information is correct.
agree to. comply with all cityand county ordinances and state laws relating to building
onstruction, and hereby authorize representatives of this city to enter upon the abs ve-
mentioned property for inspection purposes:
Dat �Y �� Signature(Applicant orAgeni).
Bin # Qw—,0 : La •: vinta
Building 8i• Safety Division .
Permit #
�51�tA9 0 l S
( 23
P.O. Box 1.504, Z.6 495.Ca11e. Tampico
La Quinta, CA 92253. (7,60)'777.7,012.
' A
Building P" -'i Application and Tracking'Sheet
Project Address:
Owner s Name Q
A. P. Number:
*'A'd'dress: `
Legal Description:
City, ST, Zip:
La
Contractor:
TI
eehn•
o e. _
P •
Address:
' Project,Descrption:
City, ST, Zip:
-
f .�,
P . O':
Telephone:
ele h
Po .
State Lic. # :
City Lic. #.:
Arch., Engr., Designer:
,
Address:
City, ST, Zip:
.;
Telephone:
one:
........,,;,.;,;;;;;;;.:,
Con tr
s ucti 'n Type' e@, Occupancy:
X P
State Lic. #
Erojec6type (circle one New Add Alter Repair Demo
Name of Contact Person:
(4o.
Sq.. Ft.:
# Stories:.
#Units:
Telephone # of Contact Person: T' b d
..alci q) (9 j
Estimated.Vilud'of Project: '
i`.
APPLICANTf DO NOT WRITE BELOW,THISttlNE
#
Submittal
Req'd
"• Rec'd
TRACKING '
"'PERMIT FEES
Plan Sets
Plan Check submitted
-Ite''m _
Amount
Structural Calcs.
Reviewed, ready;for corrections .
Plan -Check Deposit
Truss Calcs.
:Called Contact Person.
Plan Check Balance,
Title 24 Cales.
Plans picked,up ,
Construction
Floodplain plan
Plans resubmitted
Mechanical '
Grading plan
2 °Review; ready for correc1tions/issueT1
•,Electrical
Subcontactor List .
Called Contact Person_'"
:Plumbing' . `
Grant Deed
Plans picked up
S.1VLL
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
'. d 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
Total Permit Fees
W,
Description: GAS TEST INSPECTION TO CONVERT FROM PROPANE TO NATURAL GAS
Type: SPECIAL INSPECTION Subtype: Status: APPROVED
Applied: 6/24/2015 JFU
Approved: 6/24/2015 JFU
Parcel No: 773282020 Site Address: 52655 AVENIDA RUBIO LA QUINTA,CA 92253
Subdivision: SANTA CARMELITA VALE LA QUINTA Block: 165 Lot: 7
Issued:
UNIT 17
Lot Scl Ft: 0 Building Sq Ft: 0 Zoning:
Finaled:
Valuation: $950.00 Occupancy Type: Construction Type:
Expired:
No. Buildings: 0 No. Stories: 0 No. Unites: 0
Details: SPECIAL INSPECTION TO CONDUCT GAS TEST IN ORDER TO OBTAIN GAS RELEASE TOGAS COMPANY. CONVERSION FROM PROPANE
TO NATURAL GAS. THIS PERMIT DOES NOT INCLUDE ANY PIPING OR ALTERATION TO THE GAS SYTEM. 2013 CALIFORNIA PLUMBING
CODE.
CONDITIONS
Printed: Wednesday, June 24, 2015 4:31:32 PM 1 of 2
SYS7Eti1S
pe
TOTALS: $72.52 $72.52
INSPECTIONS
SEQID' INSPECTIONTYPE INSPECTOR SCHEDULED
DATE '
COMPLETED
DATE
RESULT REMARKS.: NOTES
-.
FINAL" BLD
PARENT PROJECTS
BOND INFORMATION
Printed: Wednesday,.lune 24, 2015 4:31:32 PM 2 of 2
SYSTEMS