BRES2016-0151Applicant:
DERYK AIREY
40262 EASTWOOD LANE
PALM DESERT, CA 92211
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: B. C29, C53 License o.: 962128
,:5:9�ite: ` _�<Untractor•.
OWNER -BUILDER DECLARATIO
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 !I
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 workfor which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's
VOICE (760) 777-7125
FAX (760) 777-7011
TI NO S(•7.60) 777-7153
Contractor:
DERYK AIREY
40262 EASTWOOD LANE
PALM DESERT, CA 92211
(760)497-7654
Llc. No.: 962128
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: V Applicant:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION VERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES ANUCIVIL 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: ,,nature (Applicant or Agent):
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING PERMIT
Application Number:
BRES2016-0151
Owner:
Property Address:
81888 RANCHO SANTANA DR
RYAN HENDRI
APN:
767740008
81888 RANCHO SA 7
Application Description:
HENDRICKS RESIDENCE / GAS & ELECTRIC
LA QUINTA, CA 92253
Property Zoning:
Application Valuation:
$800.00
Applicant:
DERYK AIREY
40262 EASTWOOD LANE
PALM DESERT, CA 92211
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: B. C29, C53 License o.: 962128
,:5:9�ite: ` _�<Untractor•.
OWNER -BUILDER DECLARATIO
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 !I
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 workfor which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's
VOICE (760) 777-7125
FAX (760) 777-7011
TI NO S(•7.60) 777-7153
Contractor:
DERYK AIREY
40262 EASTWOOD LANE
PALM DESERT, CA 92211
(760)497-7654
Llc. No.: 962128
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: V Applicant:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION VERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES ANUCIVIL 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: ,,nature (Applicant or Agent):
DESCRIPTION. -� `
FINANCIALINFORMATION
ACCOUNT €:. " QTY .
AMOUNT. PAID E
•PAID DATE
BSAS SB1473 FEE
101-0000-20306
0
$1.00 $1.00
6/1/16
`PAID BY,
.METHOD
.' RECEIPT #' - CHECK #
CLTD BY ,
DERYK AIREY
CHECK
MR305 2043
MFA
Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00. $1.00
r DESCRIPTION
' ` ACCOUNT ,"; ."
H QTY
AM OUNT« `
PAID
PAID DATE
DEVICES, FIRST 20
101-0000-42403
0
$24.17
$24.17
6/1/16
PAID BY;
}` ` -,; METHOD
' ` RECEIPT #+ F
= s CHECK # e e
CLTD, BY
DERYK AIREY
CHECK
MR305
2043
MFA
DESCRIPTION f
_ 'ACCOUNT
qTY
AMOUNT ,,•
« PAID t "
'PAID DATE,
DEVICES, FIRST 20 PC
101-0000-42600
0
$24.17
$24.17
6/1/16
PAID'BY ,
'..' METHOD4' : .:
RECEIPT #
` . CHECK #
CLTD BY
DERYK AIREY
CHECK
MR305
2043
MFA
Total Paid for ELECTRICAL: $48.34 $48.34
' PTION y.,
.ACCOUNT _
QTY
AMOUNT •
a PAID
PAID DATEDESCRI
PERMIT ISSUANCE
101-0000-42404
0
$91.85
$91.85
6/1/16
PAID BY,. : , r{.,
_ METHOD,,. =
RECEIPT#
CHECK#.`.„” `
CLTD BY
DERYK AIREY
CHECK
MR305
2043
MFA
Total Paid for PERMIT ISSUANCE: $91.85 $91.85
DESCRIPTION
ACCOUNT', � '
QTY'.
i` ' . AMOUNTri
x .:PAID
PAID DATE
GAS SYSTEM, 1-4 OUTLETS
101-0000-42401
0
$12.09
$12.09
6/1/16
r PAID BY
METHOD
RECEIPT,#
`CHECK #
CLTD BY:
DERYK AIREY
CHECK
MR305
2043
MFA
DESCRIPTION r k
_ _" ACCOUNT +'
QTY
i- AMOUNT ,.
PAID
'PAID DATE'
GAS SYSTEM, 1-4 OUTLETS PC
101-0000-42600
0
$24.17
$24.17
6/1/16
1' PAID BY
;- METHOD
i RECEIPT #
CHECK #
CLTD BY
DERYK AIREY
CHECK
MR305
2043
MFA
Total Paid for PLUMBING FEES: $36.26 $36.26
• ,
Description: HENDRICKS RESIDENCE / GAS &.ELECTRIC
Type: BUILDING, RESIDENTIAL
Subtype: DWELLING - SINGLE Status: ISSUED
Applied: 6/1/2016 MFA
FAMILY DETACHED
Approved: 6/1/2016 MFA
Parcel No: 767740008 Site Address: 81888 RANCHO•SANTANA DR LA QUINTA,CA 92253
Subdivision: TR 31202-3
Block: Lot: 8
Issued: 6/1/2016 MFA
Lot Sq Ft: 0
Building Sq Ft: 0 Zoning:
Finaled:
Valuation: $800.00
Occupancy Type: Construction Type:
Expired: 11/28/2016 MFA
No. Buildings: 0
No. Stories: 0 No. Unites: 0
Details: GAS STUB & ELECTRIC FOR FUTURE BBQ. PER 2013 CALIFORNIA BUILDING CODE
FINANCIAL INFORMATION
Printed: Wednesday, lune 01, 2016 11:12:15 AM 1 of 2' .
SYSTEMS
DESCRIPTION
. •
T s ACCOUNT",,.-
-
QTY
AMOUNT
a
- PAID
PAID DATE
,RECEIPT #
;'
CHECK # t
. METHOD
_ PAID BY. • - "_
CLT
• -
-
r•
"�
_.
• BY'
BSAS SB1473 FEE
101-0000-20306
0
$1.00
$1.00
6/1/16
MR305 '
2043
CHECK
DERYK AIREY
MFA
Total Paid for BUILDING STANDARDS ADMINISTRATION $1.00 $1.00
BSA:
DEVICES, FIRST 20
101-0000-42403
0
$24.17
$24.17
6/1/16
MR305
2043
CHECK
DERYK AIREY
MFA
DEVICES, FIRST 20 PC
101-0000-42600
0
$24.17
$24.17
6/1/16
MR305
2043
CHECK
DERYK AIREY
MFA
Total Paid for ELECTRICAL: $48.34 $48.34
PERMIT ISSUANCE
101-0000-42404
0
$91.85
$91.85
6/1/16
MR305
2.043
CHECK
DERYK AIREY
MFA
Total Paid for PERMIT ISSUANCE: $91.85 $91.85
GAS SYSTEM, 1-4
101-0000-42401
0
$12.09
$12.09
6/1/16
MR305
2043
CHECK
DERYK AIREY
MFA
OUTLETS
GAS SYSTEM, 1-4
101-0000-42600
0
$24.17
$24.17
6/1/16
MR305
2043
CHECK
DERYK AIREY
MFA
OUTLETS PC
Total Paid for PLUMBING FEES: $36.26 $36.26 .
TOTALS: $177.45 $177.4S
INSPECTIONS . .
PARENT PROJECTS
BOND INFORMATION
ATTACHMENTS
Printed: Wednesday, lune 01, 2016 11:12:15 AM 2 of 2
SYS7ENIS
:0.4"
. .... .. ....
4 N. �x .
Mv:
.-A
ZI
Bin #
Qty of La Q ul in t o
Building u Safety Division
78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
Project Address: 1 $�� " S
Owner's Name:
A. P. Number:
Address: g
Legal Description:
City, ST, Zip:
Contractor:
Telephone: '
P
..............
Address: -7 Q C.)/
Project Description:
City, ST, Zip: 4 as
l'
Tele P hone -b 9 S
a7 7
"Lic.
State Lic. # : 9 �j of
City #:
Arch., Erign, Designer:
Address:
City., ST, Zip:
Telephone:
n
Costru t'
c i n Type:
o Occupancy:
State Lic. #
Pr oJect type ( circle one d Alter )• New A
d'n A r Repair Demo
Name of Contact Person:Sq.
Ft.:
# Stories:
# Units:
Telephone # of Contact Person: 7 7 65
Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rec'd
TRACKING
PERMIT FEES
Plan Sets
Plan'Check submitted
Item
Amount
Structural Cales. .
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Title 24 Cales.
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
H.O.A. Approval
Plans resubmitted
Grading
IN I10USE:-
'"! Review, ready for correct ionstissue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees,
Total Permit Fees