BPLB2016-009978-495 CALLE TAMPICO D
LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT
BUILDING PERMIT
Application Number: BPLB2016-0099
Property Address: 78605 SANITA DR
APN: 604174008
Application Description: CHANGE OUT (1) 40 GALLON GAS WATER HEATER
Property Zoning:
Application Valuation: $900.00
Applicant:
STATEWIDE SERVICES INC DBA STATE WIDE PL
36947 COOK ST STE 104
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: C36, A. C33, C10 License No.: 936147
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).:
(_J I, as owner of the property, or my employees with wages as their sole
compensation, will do thg 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 Name:
Lender's
VOICE (760) 777-7125
FAX (760)'777-7011
INSPECTIONS (760) 777-7153
Date: 8/2/2016
Owner:
BRIAN WAGNER
P 0 BOX 40089
LONG BEACH, CA 92253
Contractor:
STATEWIDE SERVICES INC DBA STATE WIDE PL
36947 -COOK ST STE 104
PALM QESERT, CA
(442)666-8858
Llc. No.: 936147
. 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: BENCHMARK INSURANCE COMPANY Policy Number: CSTS007723
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,LA50R 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 thatJ 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):
Date: 8/2/2016
Application Number: BPLB2016-0099 Owner:
Property Address: 78605 SANITA DR BRIAN WAGNER 1
APN: 604174008 P 0 BOX 40089'
Application Description: CHANGE OUT (1) 40 GALLON GAS WATER HEATER LONG BEACH, CA 92253
Property Zoning:
Application Valuation: $900.00
Applicant: Contractor:
STATEWIDE SERVICES INC DBA STATE WIDE PL STATEWIDE SERVICES INC DBA STATE WIDE PL
36947 COOK ST STE 104 36947 COOK ST STE 104
PALM DESERT, CA 92211 PALM DESERT; CA
(442)666-8858
Llc. No.: 936147
Detail:
j
DESCRIPTION
'ACCOUNT '`.'<' QTY
AMOUNT
BSAS SB1473 FEE
101-0000-20306', 0
$1.00
Total Paid for BUILDING STANDARDS ADMINISTRATION BSA:,
$1.00
DESCRIPTION
ACCOUNT,
."QTY
AMOUNT
Credit'Card Fee
101-0000,43505:
0
$2.47
Total Paid for. Credit Card Fee:
$2.47 '
DESCRIPTION
'ACCOUNT
QTY
AMOUNT
PERMIT ISSUANCE
101-0000-42404''
0
$91.85
,Total Paid fo'" ' ERMIT ISSUANCE:
$91.85
DESCRIPTION•
ACCOUNT
QTY'
AMOUNT
WATER HEATER/VENT
101"0000-42401
: ?0
$12.09
DESCRIPTION
" ACCOUNT.
QTY
AMOUNT
WATER HEATER/VENT PC'
101-0000-42600
'0
$7.25
Total Paid for PLUMBING FEES:.
$19.34
Description: CHANGE OUT (1) 40 GALLON GAS WATER HEATER
CHRONOLOGY
Type: PLUMBING - WATER HEATER Subtype:
Status: ISSUED
Applied: 7/27/2016 ECON
CHANGEOUT (WEB)
Approved: 7/27/2016.ECON
Parcel No: 604174008 Site Address: 78605 SANITA DR LA QUINTA,CA 92253
Subdivision: TR 23269 Block:
Lot: 173
Issued: 7/27/2016 ECON
Lot Sq Ft: 0 Building Scl Ft: 0
Zoning:
Finaled:
Valuation: $900.00 Occupancy Type:
Construction Type:
Expired: 1/23/2017 ECON
No. Buildings: 0 No. Stories: 0
No. Unites: 0
Details:
STATEWIDE SERVICES INC DBA STATE
36947 COOK ST STE 104
ADDITIONAL
CHRONOLOGY
CONDITIONS
CONTACTS
NAME TYPE
` `NAME : -
w', ADDRESSl,
CITY
STATE
ZIP . '
PHONE
APPLICANT
STATEWIDE SERVICES INC DBA STATE
36947 COOK ST STE 104
PALM DESERT.
CA
92211
(442)66.6-8858
STATEWIDEPLUMBING
WIDE PL
2010@YAHOO.COM
CONTRACTOR
STATEWIDE SERVICES INC DBA STATE
36947 COOK ST STE 104
PALM DESERT
CA
(442)666-8858
STATEWIDEPLUMBING
WIDE PL
2010@YAHOO.COM
OWNER
BRIAN WAGNER
P 0 BOX 40089
LONG BEACH
CA
92253
(442)666-8858
FINANCIAL INFORMATION
Printed: Tuesday, August 02, 2016 9:04:21 AM 1 of 3
SYS TEAM1S
INSPECTIONS
PARENT PROJECTS
Printed: Tuesday, August 02,20159:0421AM 2nf3 OrwlYSTIMS
.PAID DAT
201607271
BSAS SB1473 FEE
101-0000-20306
0,
$1.00
$1.00
7/27/16
WEB923
451031180
CREDIT
TRICIA MORA
ECON
Total Paid for BUILDING STANDARDS ADMINISTRATION
2016072711
-1
Credit Card Fee
101-0000-43505
0
$2.47
$2.47
7/27/16
WEB923
451031180
CREDIT
TRICIA MO A
R
ECON
Total Paid for Credit Card Fee: $2.47 $2.47
2016072711
PERMIT ISSUANCE
1011-0000-42404
0
$91.85
$91.85
7/27/16
WEB923
451031180
CREDIT
TRICIA MORA
ECON
Total Paid for PERMIT ISSUANCE: $91.95 $91.8S
201607271
WATER HEATER/VENT
101-0000-42401
0
$12.09
$12.09
7/27/16
WEB923
451031180
CREDIT
TRICIA MORA
ECON
WATER HEATER/VENT
201607271
101-0000-42600
0
$7.25
$7.25
7/27/16
WEB923
451031180
CREDIT
TRICIA MORA
ECON
PC
Total Paid for PLUMBING FEES: $19.34 $19.34
INSPECTIONS
PARENT PROJECTS
Printed: Tuesday, August 02,20159:0421AM 2nf3 OrwlYSTIMS
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