12-0117 (RER)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number.
0000117
Property Address:
4876-4'—CLASTC--DR
APN:
658-130-011-5 -31379 -
Application description:
REMODEL - RESIDENTIAL
Property Zoning:
LOW DENSITY RESIDENTIAL
Application valuation:
2200
Applicant:
c&t!t 4 e(Pa"
Architect or Engineer:
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
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 Professionals Cod n y License is in full force and effect.
License Class: B Lice e N 581497
ate: ntracto .
/ OWN ER DECLARATION
I hereby affirm under penalty of perjury at 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).:
(_ 1 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—) 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 Address:
LQPERMIT
Owner:
RON ADOLPHSON
48769 CLASSIC DRIVE
LA QUINTA, CA 92253
Contractor:
NICHOLAS INC, TD
P.O. BOX 1543
WILDOMAR, CA 92595
(951)24572559
Lic. No.: 581497
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 2/08/12
I
201 f 9
GETY
qta tt,�:N
r 7
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
V issued.
►,_1 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 EVEREST NATL Policy Number 7600006962111
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
700 of the Labor Cod shall forthwith pl with those provisions.
BatZ6Ve: plican .
WARN G: FAILURE TO SE JREORKERS'CO P SATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TOAL PENALTI 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 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 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 4o, and shall defend, indemnity 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. Jagree to comply with all
city and county ordinances and state laws relating to building constru tion, and her thorize representatives
;�e:�ignature
upon the above-mentioned property f pection purpo
(Applicant or Agen
Application Number . . . . . 12-00000117
Permit . . . BUILDING PERMIT
Additional desc . .
Permit Fee . . . . 54.00 Plan Check
Fee
35.10
Issue Date . . . . Valuation
2200
Expiration Date 8/06/12
Qty Unit Charge Per
Extension
BASE FEE
45.00
1.00 9.0000 THOU BLDG 2,001-25,000
9.00
-------------------------------------------------------
Special Notes and Comments
-------
--------------
RE INSULATE EXTERIOR WALLS WHERE
NECESSARY WITH R-19 INSULATION &
RE -INSULATE INTERIOR PARTY WALL WITH
R-13 FOR SOUND. RE -DRYWALL WITH 5/8"
TYPE X DRYWALL WHERE REMOVED DUE TO
WATER DAMAGE. 2010 CODES.
-------------------------------=------------------=-------------------------
Other Fees . . . . . . . BLDG STDS ADMIN (SB1473)
1.00
Fee summary Charged Paid Credited
--------------------
----------
Due
---------------------------
Permit Fee Total 54.00 .00
:00
54.00
Plan Check Total 35.10 .00
.00
35.10
Other Fee Total 1.00 .00
.00
1.00
Grand Total 90.10 .00
.00
90.10
LQPERM IT
v
D -i
pp
c
m -n
r
M-Ozo
oO
90
� O90
>DrD
c<
10
-�M�c
ZC7oz
�D
I9'•ur .
.ScitA .E
WY1 ERZ- 14EM 04 70 W*TU. bqMIME.
WATER BOX RECESS
OJ. am VENT 10 MRSIDE
_ _.. _�'2._._._ ._3._0�_._... Y=O�. _. �'-fO• _7-2� _ 2'-10•_ 1'-10' _O'-O� ... ID's• ... __.......-.-..A._ "' 0,4• �-0-'
Bin.A
Permit #P.O.
Project Address: .. �i_ xp
Oty. of La Quinta
Buffdfng 8L Safety Division
Box 1504,78-495 Caffe Tampico
La.Qufnta, CA 92253 - (760) 777-7012
Building Perinit Application and Tracking Sheet
L Owner's Name:.
A. P. Number.
Address: .
Legal Description:
Contractor.
C1ty, ST, Zip: �U
Telephon :
Address:48 Q_
/J`�/Ly1� 3GiProject
Description: —,7— (O&Arg v
City, ST, 4:CUIC
I Z S
Telephon :
State Lie. #:
Lic. #
71 —4
Arch.; Engr., Designer.
�2 f,- 6 Pk,&42,%4 .
Address:
Ct�lTj S " zc ? v t"_c1(-l! y
City., ST. zip:
M 0 V
Telephone:
State Lic. #:
Name of Contact Person:
Construction Type:. Occupancy:
2 Project type (circle one): New Add'n Alter Repair Demo
Sq. Ft.: # Stories: # Unit;;:
Telephone # of Contact Person:
Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd'Rec'd
TRACICGVG PERMff FEES
Plan Sets
PIan Cheek submitted Item Amount
Structural Cales.
Reviewed, ready for corrections Plan Check Deposit. .
C21er•
Called Contact Person Plan Check Balance
Title 24 Calci.
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.L
H.O.A. Approval
Plans resubmitted Grading
IN HOUSE--
''' Review; ready for. corrections/tssue Developer Impact Fee
planning Approval
Called Contact Person A.I.P.P.
Pub. Wks. Appr '
Date of permit Issue
School Fees
Total Permit Fees