12-0729 (PLBG)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
T-�df 4 4 Q"
BUILDING & SAFETY DEPARTMENT
BUILDING -PERMIT
Application Number: 12-00000729 Owner:
Property Address: 5379.5 AVENIDA CORTEZ NONDERLEY RESIDENCE
APN: 774-141-014--3 =000000-, 7021 ELLENDALE DRIVE
Application description: PLUMBING BRENTWOOD, TN 37027
Property Zoning: COVE RESIDENTIAL
Application valuation: 2800
Applicant: Architect or Engineer:
4
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LICENSED CONTRACTOR'S DECLARATION
1 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 Professionals Code, and my License is in full force and effect..
License Class:_ B C36ense No:: 746760
01
Date d 'f d- contractor: — ...c._
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that lam exempufronl the Contractor'& 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 Seaton 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�aWlicamsfor a permit subjects the applicant to a civil penalty of not:more than five hundred dollars (8500).:
l _ 1 I, as owner of theproperty, 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 Llcense.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,buiiding or improvemem'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.contraaors 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'amtraaor(s) licensed
pursuant to the Contractors' State License Law.).
(_ 1 I am exempt under Sec. , 9:&P,C. for this reason
Date: Owner:
CONSTRUCTION LENDING AGENCY
I herebyaffirm under penalty of perjury that there is a construction lending agency for the performance of the.
work for which thlapermitis issued (Sec. 3097, Civ. C.).
Lender's, Name:,_
Lender's Address:
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 6/.29/12
Contractor:
B & M CONSTRUCTION/PLBOX 1977
LA QUINTA, CA 92247 "JUL 0220121 2012
(760)578=0406 4
LiC. No.: 746760
WORKER'S COMPENSATION DECLARATION
1 hereby affirm underpenalty of perjury one of the following declarations:
I. have and will maintain a certificate, of consent to selfAnsure 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.performanceof the work for which this permit is Issued. 'My'workers' compensation
insurance caller and policy.number are:
Carrier STATE FOND Policy Number
_ 1 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, 1 hall forthwith. y with those provision
Date:. "-01y Applicant:
WARNING: FAILURE TO SECURE' WORKERS' COMPEN TION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYERiTO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (8100,000). 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 Director of Building and Safety for a.permit subject to the
conditions and restrictions set forth on this application.
,1.. Each person upon whose behalfthisapplication 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 Quints, its officers, agents and employees for any act or omission relatedto 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 cornmenced
within 180 days from date of issuance of such permit, or cessation of work for 180 days,will subject
permit to. cancellation.
1 certify that I haveread this application and state that the.above information is correct. I agree to comply with all
Cityand county ordinances and state laws relating to building construction, and h eby author a representatives
of this county
to enter upon the above-mentioned property f inspection pU
Date:(*_a t _� aSignature (Applicant or Agent): ._ r
r
LQPERMIT
Application Number . . . . . 12-00000729
Permit. . . PLUMBING SEWER
Additional desc .
Permit Fee 30.00
Plan Check Fee
.00
Issue Date . .
Valuation . .
2800
Expiration Date 12/26/12
Qty Unit Charge Per
Extension
BASE FEE
15•.00
1.00 15.0.000 EA PLB BUILDING SEWER
15.00
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Special Notes and Comments
---------
TIE INTO CITY SEWER, ABANDON SEPTIC
TANK.
--_---------------.-.------------------------------------------------------
Other Fees . . . . . . . BLDG STVS ADMIN (SB1473)
1.00
Fee summary Charged Paid
---------- ----------
Credited
-------
Due
-----------------
Permit Fee Total 30.00
.0.0 .00
30.00
Plan Check Total .00
.00 .00
.00
Other Fee Total 1.00
.00 .00
1.00
Grand Total 31.00
.00 .00
31.00
COACHELLA VALLEY WATER DISTRICT
P.O. BOX 1058, COACHELLA, CALIFORNIA 92236 (760) 398-26S1
moict Dole: WIWM12
SUBJECT: SOC ONLY WGIS AVENIDA CM= LA CIUMA, LID MW46-
WONDERLEY ERIC P
prqwt
--12-3895
7021 ELLENDALE DRIVE
Project Daft..
6119=12
Amount Due:
$4.231.00
BRENTWOOD, TN 37027
Geo:
06-M12-3
Planner.
CAROL PFANNKUCHE
TO MM PROM MOM PMSE RET M Me POW= MH
mu, TmmAm mmucEmommiEcrcm YOUR orm
SUBJECT. -SOC ONLY - UM AVENDA CORTEZ LA QUINTkUD OW40
COACHELLA VALLEY WATER OISTIKXCT
P.O. BOX 2058, COACHELLA, CALIFORNIA 92236 (760) 398-2651
Pop I
11M ff
Permit
I Q __ 12-q
City of L.a Quinta
Building 8r Safety DAdsion
P.O. Box 1504, 76-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
N
Je Project Address: g' '? C( 5 AVe Co je "er's Name: c F Ltb POer, le
.3
A. P. Number: JAddressl
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Legal Description: city, ST, Zip: &
elephone-
161 Contractor: 4
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Address: P. C), 1 -7 7
City, ST, Zip.,., L
L .a 53
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4 Telephone:0 C7 C)
...........
State Lic. # - f) C City Lic.,#:
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone:
.... ... .....
State Lic. #:
Name,of Contact Person:
Telephone # of Contact Person: 7 0 ^ 7 5 Lf 6-C,
Description: T( t_ -
I CL d C?"
Construction Type: Occupancy:
Project type (circle one): New Add'n Alter Repair Demo
Sq. Ft.. I # Stories: I # Units:
�stimated Value of Project: '7' �oeq'
DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rec'd
TRACKING
PERMITTEES
Plan Sets
Plan Check submitted
Amount
Structural CaIcs.
Reviewed, ready for corrections
Plan Check,Deposit
Truss CoIcs.
Called Contact Person
Plan Check Balance
Title 24 Cales.
Plaits picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2" Review, ready for corrections/issue
Electrical
'Subiontactor List
Called Contact Person
Plumbing
Grant Deed
Planspicked up
S.
MO.& Approval,
*Plans resubmitted
Grading
Review, ready for correctionOssue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total,Permit Fees