14-0829 (SPIN)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: M
T4.-00:0:0;0:82;9
Property Address:
51045 AVENIDA RAMIREZ
�► APN:
773-061-013-2 -000000-
Application description:
SPECIAL INSPECTION
Property Zoning:
COVE RESIDENTIAL
Application valuation:
0
Applicant: Architect or Engineer:
�JA
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LICENSED CONTRACTOR'S DECLARATION
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
I hereby affirm under penalty of perjury that 1 am licensed under provisions of Chapter 9. (commencing with
Section 7000) of Division 3 of the Business and Professionals Code, -and my License is in full force and effect.
License Class: License No.:
Date: Contractor:
OWNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that I -am exemptfrom the Contractor's State License Law for the
following reason (Sec. 703.1.5, Business and-ProfessiorisY 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 Cade) or -
that he or she is exempt therefrom and the basis for the allegedexemption. Any violation of Section 7031.5 by
QQP applicant fora permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
(Y") 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.).
(_ 1 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.).
(_ 1 I am exempt under Sec. , B.&P.C. for this reason
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: .�
LQPERMIT
Owner:
PATRICK CHYLIK
51045 AVENIDA RAMIREZ
BERMUDA DUNES, CA 92203
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 6/11/14
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Contractor:
Owner �i45d v. 1
E
WORKER'S COMPENSATION DECLARATION
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 wilFinaintain 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 sub'ect to the workers' compensation provisions of Section
• /' 00 of the Labor r Code, I sh IYfb ith com i t those provisions..
Date: f7 �G -Applicant: /
WARNING: FAILURE TO SECURE WORKERS' CO ENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENAL IES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($100,000). IN ADDITIONTO.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 persori 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 count o ter upon the above-mentioned property for i s ecti n pur ses.
ature (Applicant or Agent):
Application Number . . . . . 14-00000829
Permit . . . SPECIAL INSPECTION
Additional desc . .
Permit Fee . . . . 71.50 Plan Check Fee .00
Issue Date . . . . Valuation . . . . 0
Expiration Date . . 12/08/14
Qty Unit Charge Per Extension
1.00 71.5000 EA MISC SPECIAL INSPECTION 71.50
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Special Notes and Comments
SPECIAL INSPECTION TO VERIFY
INSTALLATION OF NEW BREAKER - NO NEW
CONSTRUCTION.
June 11, 2014 12:58:26 PM khensel.
Fee summary Charged Paid Credited Due
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Permit Fee Total 71.50 .00 .00 71.50
Plan Check Total .00 .00 .00 .00
Grand Total 71.50 .00 .00 71.50
LQPERMIT
_ 'i
Bin #.City
of La Quinta
Building 8i Safety Division
P.O. Box 1504,78 Calle Tampico .
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and. Tracking Sheet
Permit #-
�A495
; ��
Project Address:
Owner's Name: oDt /
A. P. Number:
Address:
�H/ 4� /NI✓CL
Legal Description:
City, ST, Zip: G� QG�1Z--T
Contractor:
Telephone: 76d 333 -W,1,7
Address:
Project Description:
City, ST, Zip:
Telephone:
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State Lie. # :
City Lie. #:
Arch., Engr., Designer:
Address:
City., ST, Zip:
.
Telephone:
State Lie. #:
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Construction Type: Occupancy:
w Add'n Alter air
Project type (circle one): New Rep Demo
Name of Contact Person:
Sq. a:
# Stories:
#Units:
Telephone #:of Contact Person:
Estimated Value of Project:
APPLICANT: DO NOT _WRITE BELOW THIS LINE
#
Submittal
Req'd
Recd
TRACKING
PERMIT FEES.
Plan Sets
Plan Check submitted
Item
Amount
Structural Cates.
Reviewed, ready for corrections
Plan Check Deposit
Truss C21e5.
Called Contact Person
Plan Check Balance
Title 24 Calcs.
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.
II.O.A. Approval
Plans resubmitted
Grading
IN IiOUSE:-
'^'. Reyiew, ready for correctionsrissue
Developer Impact Fee
Planning Approval
. Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total PermitTecs