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13-0975 (MECH)r P.O. BOX 1504 .78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: 13-00000975 Property Address: 78495 CALLE TAMPICO APN: 7707130-001- - - Application'description: MECHANICAL Property Zoning: MAJOR COMMUNITY FACILITY Application valuation: 0 Applicant: Ti BUILDING & SAFETY DEPARTMENT BUILDING PERMIT Owner: CITY OF LA QUINTA 78495 CALLE TAMPICO LA QUINTA, CA 92253 Architect or Engineer: Contractor: Owner VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 8/05/13 AUG ps 2013 • Sp - Are -M= ufFfNANCE DEPT. SIB, cbl�1T� ; • T+>.Yn42S .Ali alp. lAIG I`�� ---------------------------------------=--------------------------------------------------------- F7F.W LICENSED CONTRACTOR'S DECLARATION WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury that I am licens un rovisions of Chapter 9 (commencing with I hereby affirm under penalty of perjury one of the following declarations:, section 70001 of Division 3 and Profes ionals Cod an License is in full orce and effect. I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided of&Eu049)s License Class: Licen _ for by Section 3700 of the Labor Code, for the performance of the work for which this permit is ���- �ate:f y,1 contractor. issued. t/ 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. - OWNER -BUILDER DECLARATION insur ce carrier �n�d� Qoli�cy number are: I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the Carri�,�f,� . 4W UVFFT Policy Number Wj -following reason (Sec. 7031 .5, Business and Professions Code: Any city or county that requires a permit to _ I certify that, i the perform nee of the work for which this permit is issued, I shall not employ any construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the person in any manner so as to become subject to the workers' compensation laws of California, permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State and agree that, if 1 should -become suble�S o [hew rkers' compensation provisions of Section License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 3700 of the Labo _ode, shall forthwA crt _ with those rovisions. 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 1$5001.: Date: � 14pplicant: - -1-_) I, as owner -of -the -property, or my employees with wages as their sole compensation; -will do thework, and- - -- - - - - - -- - - -- - -- - -- --- --- - - •--- - - - - - - - • -- - - — - _. �__ __.- the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The WARNING: FAILURE TO SECURE WORKERS' COMPE ION COVERAGE IS UNLAWFUL, AND SHALL Contractors' State License Law does not apply to an owner of property who builds or improves thereon, SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND and who does the work himself or herself through his or her own employees, provided that the DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN improvements are not intended or offered for sale. If, however, the building or improvement is sold within SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. - 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.). - - APPLICANT ACKNOWLEDGEMENT (_) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. r IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of conditions and restrictions set forth on this application. property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed 1.. Each person upon whose behalf this application is made, each person at whose request and for ` pursuant to the Contractors' State License Law.). whose benefit work is performed under or pursuant to any permit issued as a result of this application, 1 _ 1 I am exempt under Sec. , B.&P.C. for this reason the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City 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 of La Qwnta, 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 isle rrect. I agree to comply with all city and county ordinances and state to building c ructi , and ereby authorize representatives of thio my to enterupon th ove-mentioned operty f9 inspection oses. Date: /Signature (Applicant o e - Application Number 13-00000975 ------ Structure Information EXISTING COUNCIL CHAMBERS ----- Other struct info . . . . . CODE EDITION" ---------------------------------------------------------------------------- 2010 Permit . . . MECHANICAL 2013 Additional desc.: Permit Fee . . . . -" .00 Plan Check Fee 00 . Issue Date, 8/05/13 Valuation . . . 0 Expiration Date 2/02/14 Qty Unit Charge Per Extension 1.00 .0000 EA MECH CONDENSER/COMP .00 --------------------------------------=---=--------------------------------- Special Notes and Comments REMOVE EXISTING HVAC SYSTEM #3 CONDENSER UNIT WITH NEW 50 TON CONDENSER ON NEW MOUNTING PLATFORM ON EXISTING MOMENT FRAME STRUCTURE. COUNCIL CHAMBERS AREA. CONTRACTOR:F.M. THOMAS 313574; " MECH. ENGR: DAVID CELMER M22768; STR. ENGR: YOUNG ENGINEERING Fee summary Charged Paid Credited Due --- ---------- ---------- ---------- Permit Fee Total _00 .00 .00 ---------- .00 Plan Check Total .00 .00 .00 :00 Grand Total .00 .00 .00 .00 LQPERMIT WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 37 (Ed. 5-02) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT .CALIFORNIA We have the right to recover our payments from an liable for an.injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written' contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the schedule. The additional premium for this endorsement shall be 5% of the California Workers' Compensation premium otherwise due on such remuneration, subject to aminimum premium of $50.00. Schedule Person or Organization Job Description City of La Quinta, its officials, employees Re: City Hall Building HVAC System 3 and agents j Replacements, Project No. 2013-13. 78-495 Calle Tampico La.Quinta, CA 92253 i Policy Number: WSD 5005404 02 Insured: F M Thomas Air Conditioning Inc Endorsement Effective: 7/26/13 Issue Date: 7/30/13 WC 99 06 37 (Ed. 5-02) Coverage Provided by: Insurance Company of the West Countersigned by: O Check a License - License Detail - Contractors State License Board Page 1 of 2 ON. *GO V W10M. DEPARTME T OFCONSUMER AFFAIRS Contractors State License Beard Contractor's License Detail License # 313574 "f l' DISCLAIMER: A license status check provides information taken from the CSLB license database. Before relying on this information, you should be aware of the following limitations. CSLB complaint disclosure is restricted by law (B &P 71.24.6) If this entity is subject to public complaint disclosure, a link for complaint disclosure will appear below. Click on the link or button to obtain complaint and/or legal action information. Per B&P 7071.17 , only construction related civil judgments reported to the CSLB are disclosed. Arbitrations are not listed unless the contractor fails to comply with the terms of the arbitration. Due to workload, there may be relevant !information that has not yet been entered onto the Board's license database. I License Number 313574 Extract Date 8/5/2013 F M THOMAS AIR CONDITIONING INC Business Information Business Phone Number:•(714) 738-1062 231 GEMINI AVE BREA, CA 92821 Entity Corporation Issue Date .12/17/1975 Expire Date 02/28/2015 License Status ACTIVE This license is current and active. All information below should be reviewed-. _..........._._.... _.�__...._._......._..._._........ .�........ ....... _..... _.....:.... _........_a_......_.__... _.._.._........._ ................. _—.._......... __._._._................ ........ ,.................. _.... _..... ,._.... _.... _....._...._..... _........... ...... _..:..... ......._ The license may be suspended on 09/04/2013 if a current workers" compensation Additional Information insurance policy is not ,filed with the CSLB. DESCRIPTIONCLASS Classifications W6 REFRIGERATION B GENERAL BUILDING CONTRACTOR INDEMNITY COMPANY OF CALIFORNIA. Bond.Number: 612570C Bond Amount: $12,500, Bonding Effective Date: 01/01/ 2007 Contractor's Bond History 1. The Responsible; Managing Officer (RMO) FEYKA THOMAS MICHAEL certified that he/she owns; 10 percent or more of the voting stock/equity of the corporation. A bond of qualifying individual is not required. https://www2.cslb.ca.gov/OnlineServices/CheckLicenseII/LicenseDetail.aspx?LicNum=313574 8/5/2013 Check a License - License Detail - Contractors'State License Board Effective Date: 01/01/1980 _._...... _...__.___....____....................... .__ .......... _......_.._..__.__............. 2. 2. This license filed Bond of Qualifying Individual:number954558C for FEYKA DANIEL JAMES in the amount of $12,500 with INDEMNITY COMPANY OF CALIFORNIA: j Effective Date: 01/01/2007 BQI's Bond History ��i��.�:�aa:�:7l�ii11919. i • i This license has workers compensation insurance with Workers' Compensation Policy Number: W8D500540402 i Effective Date: 01/01/2013 Cancellation Date: 0 7/31/2013 WorkersCompensation History I r i Conditions of Use I Privacy Pollcv Copyright © 2010 State of California I .I i j I j I I http s : //www2. c slb. ca. gov/OnlineS ervices/CheckLicenseII/LicenseDetail. aspx?LicNum=3135 74 Page 2 of 2 8/5/2011