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BCOM2014-104178-495, CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 4 lwQ,�rw COMMUNITY DEVELOPMENT DEPARTMENT BUILDING PERMIT CApplication Number: BCOM2014-1041 Property Address: -- -79440 CORPORATE CENTER DR #104 APN: 600390021 Application Description: COMMERICAL TI FOR STATE FARM Property Zoning: Application Valuation: $20,000.00 (1 /1 r Applicant: ROBERT RICCIARDI 75400 GERALD FORD DR #115 PALM DESERT, CA 92211 DEC 23 2014 CITY OF LA QUINTA COMMUNITY DEVELOPMENT DEPARTMENT 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: _ 'cense No.: Contracto Date: Z .--- O ER -13 ER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason (Sec. 7031.5, Business and Professions Cod ny 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 of the Business and Professions Code) or that he or she is exempt therefrom and the 1 basis for the alleged exemption. Any violation of Section 7031.5 by any applicant f 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.). ( ) 1, 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 contractors) licensed pursuant to the Contractors' State License Law.). (� I am exempt under Sec. _ B.&P.C. for this reason ate: e Z ner: CON RU CT LENDING AGENCY I hereby affirm under penalty' hury 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: VOICE (760) 7.77-7125 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Dater 12/23/2014 Owner: JAMES PAUL 79220 CORPORATE CENTER DRIVE LA QUINTA, CA 92253 Contractor: I Llc. No.: 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' 7c pensation, as provided for by Section 3700 of the Labor Code, for the performance 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: _ Policy Number: _ I certify that in the performance of the work for which this permit is issued, I sh 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 37 f2 Labor Code, I shall forthwith comply with those prqvisions. / /J WARNING: FAILURE TO SECURE OR 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 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 buildin construction, and hereby authorize representatives of this city to enter upon a ag mentioned p perty r inspection purposes. ate Signa (ApplicantorAgent): 4 Description: COMMERICAL TI FOR STATE FARM Type: BUILDING, COMMERCIAL Subtype: REMODEL Status: APPROVED Applied: 12/5/2014 MFA Approved: 12/23/2014 JJO Parcel No: 600390021 Site Address: 79440 CORPORATE CENTER DR #104 LA QUINTA,CA NOTE 92253 12/5/2014 Subdivision: Block: Lot: Issued: Lot Scl Ft: 0 Building Scl Ft: 0 Zoning: Finaled: Valuation: $20,000.00 Occupancy Type: Construction Type: Expired: No. Buildings: 0 No. Stories: 0 No. Unites: 0 Details: ADD 990 SQ. FT. TO EXISTING STATE FARMS OFFICES WITH NEW BATHROOM, BREAK AREA AND NEW OFFICES, MODIFY FIRE SPRINKLER AND HVAC & DUCTS. PHILIP JUAREZ Applied to Approved Printed: Tuesday, December 23, 2014 3:34:44 PM 1 of 4 ! SYST(: MS CHRONOLOGY CHRONOLOGY TYPE STAFF NAME ACTION DATE COMPLETION DATE NOTES NOTE KAY HENSEL 12/5/2014 12/5/2014 1 SET OF PLANS ROUTED TO PLANNING FOR REVIEW AT BOB RICCIARDI'S REQUEST I FAXED HIM THE CORRECTION NOTE KAY HENSEL 12/23/2014 12/23/2014 LIST. THERE ARE REDLINES ON THE PLANS. HE SAYS HE WILL PICK THEM UP. PLAN CHECK PICKED UP PHILIP JUAREZ 12/23/2014 PLANS PICKED UP BY RAMON GUTIERREZ 760-485-7003 FOR MR. RICCIARDI. PLAN CHECK SUBMITTAL KAY HENSEL 12/5/2014 APPLICATION FOR PERMIT RECEIVED AT FRONT COUNTER - 12/5/2014 RECEIVED MFA CONDITIONS Printed: Tuesday, December 23, 2014 3:34:44 PM 1 of 4 ! SYST(: MS FINANCIAL INFORMATION DESCRIPTION ACCOUNT QTY AMOUNT PAID CONTACTS BY BY BSAS SB1473 FEE 101-0000-20306 0 $1.00 $0.00 Total Paid forBUILDING STANDARDS ADMINISTRATION $1.00 $0.00 NAME TYPE NAME ADDRESSI CITY STATE ZIP PHONE FAX EMAIL APPLICANT ROBERT RICCIARDI 75400 GERALD FORD DR #115 PALM DESERT CA 92211 (760)771-8932 $0.00 OWNER JAMES PAUL 79220 CORPORATE CENTER DRIVE LA QUINTA CA 92253 (760)771-8932 FINANCIAL INFORMATION DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE RECEIPT # CHECK # METHOD PAID BY CLTD. BY BY BSAS SB1473 FEE 101-0000-20306 0 $1.00 $0.00 Total Paid forBUILDING STANDARDS ADMINISTRATION $1.00 $0.00 BSA: DEVICES, ADDITIONAL 101-0000-42403 0 $26.62 $0.00 DEVICES, ADDITIONAL 101-0000-42600 0 $6.60 $0.00 PC DEVICES, FIRST 20 101-0000-42403 0 $24.17 $0.00 DEVICES, FIRST 20 PC 101-0000-42600 0 $24.17 $0.00 Total Paid for ELECTRICAL: $81.56 $0.00 APPLIANCE 101-0000-42402 0 $12.09 $0.00 REPAIR/ALTERATION APPLIANCE 101-0000-42600 0 $4.83 $0.00 REPAIR/ALTERATION PC VENT FAN 101-0000-42402 0 $12.09 $0.00 VENT FAN PC 101-0000-42600 0 $4.83 $0.00 Total Paid forMECHANICAL: $33.84 $0.00 FIXTURE/TRAP 101-0000-42401 0 $36.27 $0.00 -FIXTURE/TRAP PC 101-0000-42600 0 $36.27 $0.00 WATER HEATER/VENT 101-0000-42401 0 $24.18 $0.00 - Printed: Tuesday, December 23, 2014 3:34:44 PM 2 of 4 Or SYSTEMS DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE RECEIPT # CHECK # METHOD PAID BY CLTD SENT DATE DUE DATE RETURNED DATE, STATUS REMARKS NOTES NON-STRUCTURAL JIM JOHNSON 12/5/2014 12/19/2014 BY WATER HEATER/VENT 101-0000-42600 0 $14.50 $0.00 12/5/2014 12/19/2014 12/18/2014 APPROVED STATE FARM TI NO COMMENTS. PERMITTED OFFICE USE, NO EXTERIOR CHANGES. PC WATER SYSTEM 101-0000-42401 0 $12.09 $0.00 INST/ALT/REP WATER SYSTEM 101-0000-42600 0 $12.09 $0.00 INST/ALT/REP PC Total Paid for PLUMBING FEES: $135.40 $0.00 REMODEL, EA 101-0000-42400 0 $43.50 $0.00 ADDITIONAL 500 SF REMODEL, EA 101-0000-42600 0 $34.80 $0.00 ADDITIONAL 500 SF PC REMODEL, FIRST 100 SF 101-0000-42400 0 $49.31 $0.00 REMODEL, FIRST 500 SF 101-0000-426000 $134.88 $0.00 PC Total Paid forREMODEL: $262.49 $0.00 SMI -COMMERCIAL 101-0000-20308 0 $5.60 $0.00 Total Paid forSTRONG MOTION INSTRUMENTATION SMI $5.60 $0.00 TOTALS:00 PARENT PROJECTS REVIEWS REVIEW TYPE REVIEWER SENT DATE DUE DATE RETURNED DATE, STATUS REMARKS NOTES NON-STRUCTURAL JIM JOHNSON 12/5/2014 12/19/2014 12/23/2014 REVISIONS REQUIRED CORRECTIONS CORRECTIONS REQUIRED PLANNING WALLY NESBIT 12/5/2014 12/19/2014 12/18/2014 APPROVED STATE FARM TI NO COMMENTS. PERMITTED OFFICE USE, NO EXTERIOR CHANGES. Printed: Tuesday, December 23, 2014 3:34:44 PM 3 of 4 SYS7F.Iv1S NON-STRUCTURAL IJIM JOHNSON 112/23/2014 112/23/2014 112/23/2014I APPROVED I APPROVED S APPROVED. E DEPT. BE R IP EQUIR LD TONDO A SPRINKLER INSPECTION BEFORE BOND INFORMATION ATTACHMENTS Attachment Type.. .CREATED" . OWNER' DESCRIPTION PATHNAME SUBDIR° ETRAKIT ENABLED DOC 12/23/2014 JIM JOHNSON 79-440 CORP. CENTER 79-440 CORP. CENTER 0 DR..doc DR..doc Printed: Tuesday, December 23, 2014 3:34:44 PM 4 of 4 C#? sysrenns j � e• � o m _ -ve „�;,..,; ... '�:�'-":?f.�%�'•�S •k 1'5�'.. ,t � _.. •'�' Y'.S. > ��1+� �.7 ITh' !n'k'�" { �,Y �}'a•§4 f �h3 krlri Dh ESCRIPTION, ,ACCOUNT QTY `�: M`O�UNTU PAIDDATE= BSAS SB1473 FEE 101-0000-20306: 0 $1:00 $0.00 , HIM,PAIDBYm ���� METH OD C : REQ EIPT # CH CK #x �CLTDBY ' x Total Paid forBUILDING STANDARDS ADMINISTRATION' BSA: $1.00 $0.0040 . DESCRIPTIONA ^ ACCOUNT _ �� QTY AMOUNT" SFr. E PAID "NO z PAIDyDATE- DEVICES, ADDITIONAL 101'0000742403. 0 $26.62. $0:00 F�', rA ffl,` M �00 • .,RECEIf?T # . �`4 ,. CHECK #� CLTD B �DESCRI TIONS yy� W 3:+w`IFXA�h''.Y^".i,'�..=PH r�. ACCOUNT`' t`"+�J..`�F'+'�k..4 �Q�p` AMOUNT `� �is'2k'6,'i'.':{.YR!.$^.,•li PAID DATE .'-• DEVICES, ADDITIONAL PC 101-0000-42600' .. '0 ,$6.60 • $0.00 d P DBY �: x MM x M HOD � RECEIPT # Fes.. CHECK # � Y F CU BY.--'-'z yDESC PTI ON's - ACCO�UN� AOUNT AID f PA.ITDIDTE DEVICESJIRST20 101-0000-42403 0...1 $24.17' .. $0.00 ORION B111 s , Lam• a IliOD, " *:RECEIPT # �� CHECK # �CLTD BYE DESCR TON r .• � . ACO NT . � ,. . ��;�,� ? .x:. QT AMOUNT :; ,. � PAIS R� _ � � ,:. �... SPAID DATE DEVICES, FIRST 20 PC: 101-0000-42600 0'$24' 17. $0:00 , SIR, 'PAID BYE M TE HOD RECE(PHECK# n �CLIDBY •.Total Paid for ELECTRICAL: $81.56 $0.00, 01 M,.DESGR P7TION ..ON .. ..QTIf ;.CC N�� ��� y i4M.�. 0�,..PAIUca PAIDDATE APPLIANCE REPAIR/ALTERATION- 101-0000-42402; ° 0 '.• $12'.09 x$0,00. PAID YMETIiOU .c ��o�hi..-N'xr`.f.�T... .F",5:.' - k OWES' @. c�aS,�i'.�3+v.z �. F, R EIPT # MC � CHECKS# .vC'r,�1 *�'sY •..1� GCTUBY �%;$''':?-f9�`�-�..'S�u OUAMNT` ?.::y.i �PQID�``� � � PAID DATE APPLIANCE'RR+EPAIR/ALTERATION PC..-,,"101-0000-42600 0'• $4.83 $0.00 RT��iX�Y.R-i "I„Y✓j, 1 PAID B�'WET,HpD � k',i°i�.�.' ����P'x"�,;. : RECEIPT # CHECKS# CgSCLTD BY �DESCRIP�TION�r"' ACCO NT " QTY C" UNTn-.. ' MO 4:-PAID" r , ., X�ID�ATE pAw> u a VENT FAN ` . 101-0000-42402. 0 $12.09 :" ' $0.00 ����PAIU BYE TM Baal ..�is'4b..�6• .. METHOD A� �. eRECEI T #CHECK ',$h'YnSaa .: �A.'Y # z r CLTD BY ' ... ... ` ��������,QTY °DE�FS.GRIPTION� ra�, %, ate' .iY�&2'G ii¢�D� KT��s- - b�' Y.+m'xL�'D'�:�.+.2 ,�'trv!"u�' AMOUNT .'ru" d�'w''�•k';jEn,.s26d. ;PAID �!`v . .CcS;�4_.a-X �'o PAID DATE> �i56�`_tw.S,..b _ „"G'..�.r VENT.FAN PC. 101-0000-42600 0' • , . $4.83 $0.00 ' 't Ate' �' �v� METHODS# K"_ r ~ ,, CHECK# gxCLTBY Total'Paid.,forMECHAN[CAL:. $33:84 $0.00 c ES' IPTION��ACCOUNT ��� , .. ,. , �d QTY `AMOUNT N , PAIYUPAIDD`ATE w, d ,.. . 1_� ma x. FIXTURE/TRAP 101-0000-42401 0 $36.27 $0.00 I FINE'PAD s M171m-HUQr DT a r RECE HE#IP# C Tr;cD B .OTRnce_ ���DEcC�S:mP QtA?,3,C.AOT T M PAIc-uPs5A,uC�sLaIDO E ATY FIXTURE/TRAP_PC 101-000042600 0 $36.27.$0.00' f�PAID BY � �� r ; MOOD, REC�,E�IPT'# `w' � - CHECK # CLW - .t�', z:�r..�,$ , ri l _..fil. - .Y A COUN Q � F` ' �.��' ,x+ AMOUNT PAID x s #PA DATES WATER HEATER/,VENT.. 101=0000-42401` 0 $24.18' ' `' $0.00 .. PAID BY a � ET OD '`RECEIPT # CHECK 'Ali D BY r 1.ESCR Nlb , go4:. ' ACCOU�NTT QTLY���AA OU NT y PAI PAID DATE: WATER HEATER/VENT PC' 101-00002600 0 . $14.50 , - - $0.00 v,4 AIBP r , 4'=.0 .2a. ;; , �MIT �' .u3 . RECEIPTS# �I �,st C C #� rCLTDBY` ' �r VERN DESCRIPTION: '. ACCOUNT � QTY s AMIOUNT PAID IV F PAIDDATE,' WATER SYSTEM INST/ALT/REP • 101-000041401 0 $12.09 $0.00 ^ '"i �� s �, � AUB� � -�,,., ���� .. r�Hk `di? RECEIPT'#�` �9,aK-,f+6"'� ..,aCHECK#. CLTD BYr: 10101,011 ,,DESCRIPTION y � ACCO NT k AMO NT a 6"JPAI ,PAID DATE> WATER SYSTEM INST/ALT/REP PC• 101-0000-42600 ' 0 .. ` $12.09: $0.00: w._5... bA. i5 i., 3..�;��_'L,'"�.kF ,.,: bCc ✓rJv i�?tS.SA6. 5+i�3S5ifiiyx'iR�.Yli'xFiii�'i **.S, .y ECEIRT# *5? 3° 5*'-S'r.V,l _Y.wA'2%J"k�� 3,,5rt`,..:�kw eu .h;'K._"` r. Total Paid for PLUMBING FEES: $135.40"*,' ' ' - $0.00 ,�qcu�. <� `,DESCRIPTION r ACCOUNT' �� - QTY AMU.UNT� k$ R 41D� PAAID DATE;, REMODEL; EA ADDITIONAL 500 SF ,, ., 101-0000-42400 0 . '$43:50 $0,00 PA D BY r*4 MET,HOD RECE PT # r a CHECK # CLTD BYE f, hD SCRIRTION v p COUNT QTY AMOUNT PAID a PAID DATE REMODEL, EA ADDITIONAL 500 SF PC 101=0000-42600 0 1$34.80 $0.00 ' � ��PAID BY �� ' ' �a � C �N• �. METHOD t��ttkk �" i,asax:�a�d`::✓£� f. �.,:�i�� �� .. sn.� ECE PT'# '. ,z�nn:�� 4 • �� CHj, EW ���r,��.v;a�r,k`�.� CLTD BYss' r+;�,>r.�.~s:r 3.zTi,ia a 70 EC PTION 4 CA OU ' Tlf A O NT'`. boom= zPAID DATE REMODEL, FIRST 100 SF 101m()000-42400, 0 $49.31 $0.00. i" # ig�°�t , 'x"Y§'MINNOWS .` , �p °ABY .. � s::� �.� $5?Ayj, `"k M Ham.. a l ° � ' � RECEIPT D SC PION 'ACCOUNT La o �4 ai3�.hr:5r;'.:�:atr.z:,✓i.3"' AMOUN PAID I,u.,k'r PAI DA E ak^, REMODEL, FIRST 500,SF PC' 101-0000-4,2600,':`* °0 $134.88 $0.00. r§ �N AID BY �. �Fys Y �MEiHOD«RECE�CHECKx^#� v rn x�u b t:w�•s� N �� CLTD BY ` Total. Paid for REMODEL:, '$262.49 $0.00 t s. DESCRIPTIONa �� ACCOUNT w QT y MOUNT,, A I * ` PAID PAID°DATED SMI - COMMERCIAL 101-0000-20308 0 $5.60 $0.00 RECEI?T#- CHECK# CLTDBY Total Paid forSTRONG MOTION INSTRUMENTATION SMI: $5.60 $0.00 TdY °F 4QuGi1a P:O. BOX 1504 LA QUINTA, CALIFORNIA 92247-1504 79-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT PROPERTY OWNER'S PACKAGE (760) 777-7012 FAX (760) 777-7011 Disclosures & Forms for Owner -Builders Applying for Construction Permits IMPORTANT! NOTICE TO PROPERTY OWNER Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property .improvements specified at We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us.at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION IRECTIONS: Read and initial each.statement below to signify you understand or verify this information. I understand a frequent practice of unlicensed persons is to have the property, owner obtain an "Owner -Builder" building permit that erroneously implies that the property owner is providing his or:her ow -n labor and material personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers my property. I understand building permits are not required to be signed by property owners unless they are responsible for the :tion and are not hiring a licensed Contractor to assume this responsibility. (understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect from potential financial risk by hiring a licensed Contractor and having the permit filed in his or'her name instead of my I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on and contracts. 5. I unonderstand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value • of m struction is at least five hundred dollars ($500), including labor and materials, J may be considered an "employer" under state and federal law. 6. understand if I am considered an "employer" under state and federal law, I .must register with the state and federal government, withhold payroll taxes, provide workers' compensation "disability insurance, and contribute to unemployment compensation -for each "employee." I also understand my failure to abide by these laws may subject me to serious financial isk. 7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential ctures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any m inial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue ervice, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1- 00-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. 10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the following address: 4. I agree that, as the party,legally and financially responsible for this proposed construction activity, I will abide by all .apble laws and requirements that govern Owner -Builders as well as employers. I agree to notify the issuer of'this form immediately of any additions, deletions, or changes to any of the information I ovided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with e who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It isalso important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the ncy is required to be presented when the permit is issued to verify the property owner's.signature. Signature of property own Date: Note: Aefollowing Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder. AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Tel No Address of Authorized Agent: I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to the agency is required to He presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: Bin# �gP (�" l City of La Quinta. -Building $t Safety Division P.O. Box 1504, 78-495 Calle Tampico11A . La Quinta, CA 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet Permit # Project Addi:ess:Wr J 4 e cft► e vnl. Owner's Name: A. P. Number: Address: Legal Description: 0(� U� City, ST, Zip: ntra t Co c or. 5 one: Telephone:h � Address: 7_ a0 c Project Description: r City, ST, Zip: Te1P hone:JV e7z 7 State Lic. # : City Lie. #•: Arch., EnM. L1rsigaw► (` Address: 75 400 ria 4(6i VVJzb �. 4()(16 11,5 City., ST, Zip: Fa tl,0 Q{ C %S` q7.2-11 Tele ho n 1�P 0� l2d j:G::::S"f.:i`iiiiiSi:GiY�: . :: aneY Constructionn Type: Occupancy: • State Lic. ............................................:...:::::.. Project type (circle one): New Add'n Alter Repair Demo Name of Contact Person:p�{' (('L1 Sq. Ft.: ® # Stories: #Units: I (' Telephone #,of Contact Person: �p�� 4dg)- 1;! ®(J Estimated Value of Project: APPLICANT: DO NOT WRITE BELOW THIS LINE # Submittal Req'd Recd TRACKING PERMIT FEES Plan Sets i Plan Check submitted Item Amount Structural Calcs.Reviewed, read for corrections 2 Plan Check Deposit Truss Cala. Called Contact Pc Z Plan Check Balance. Title 24 Calcs. �Hf pf Plans picked up 1212-3 Construction Flood plain plan Plans resubmitted 1212-3 Mechanical Grading plan 2°" Review, ready for eorrectio s/issu 1-21231Electrical Subcontactor List Called Contact Person 12 2 Plumbing Grant Deed Plans picked up S.M.I. • H.O.A. Approval Plans resubmitted Grading Apr of IN HOUSE:- '"' Reyiew, ready for corrections/issue Developer Impact Fee 416 Planning Approval Called Contact Person A.I.P.P. Pub. Wks. Appr Date of permit issue School Fees Total Permit Fees 23 P kNS �AoY 7vet�3 /60-777 CITY OF LA QUINTA SUB-CONTWTOR LIS40L JOB ADDRESS -ZW6-0 C /?� G%� I-X- PERMIT NUMBER OWNER ���s, /�. BUILDER This f6rm shall be posted on the job with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this list or thv - ployees are authorized to work on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance of building permit. For each applicable trade, all information requested below must be completed by applicant. "On File" is not an acceptable response. Classt Trade:/.... _fication ..... ::. Contractor State..Contractor;s:Ltcense ,::.:. W r o kers Com ensafion nsurance _, P Crt.:Busrness: acense;::. _..y ... Company Name Classification (e.g. A, B, C-8) License Number (xxxxxx) Exp. Date (xx/ x/xx) Carrier Name (e.g. State Fund, Cal Co ) Policy Number (Format Varies) Exp. Date (xx/xx/xx) License Number (xxxx) Exp. Date (xx/xx/xx) EARTHWORK (C 12) �j S C" / �4� ll� ��07 < & CONCRETE:-(C 8).. FRAMING::(C-5)::.. [ r % �/ 3 / _ PAINTING:(C-33) . l CERAMIC TILE,(C754) CABINETS;( .=6) LANDSCA7.PING-`(C-27)Lza �/ -,r POOL-(C-5'3)