BMCH2015-013678-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
Property Address:
APN:
Application Description:
Property Zoning:
Application Valuation:
4 4v Q&&
DEVELOPMENT DEPARTMENT
WILDING PERMIT
BMCH2O15-0136
55492 LAUREL VALLEY
775181074
SKIP SVESTA REPALCE 3.5 TON SPLIT SYSTEM
$4,000.00
Applicant:
RAY'S AIR CONDITIONING AND HEA
OUTSIDE CITY LIMITS
LA QUINTA, CA 92253
APR 2 0 2015
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: _ License No.: :LIC -0111472
�CDate: q Contractor:
OWNER -BUILD R D LARATION
1 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
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.).
(1 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: 4/20/2015
Owner:
SVESTKA, ERWIN J
55492 LAUREL VALLEY
LA QUINTA, CA 92253
Contractor:
RAY'S AIR CONDITIONING AND HEA
OUTSIDE CITY LIMITS
LA QUINTA, CA 92253
(760)202-7770
Llc. No.: :LIC -0111472
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: _ Policy Number:'_
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: �' Z� 2 a Vs Applicant: /
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE I NLAWFUL,
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 building
construction, and hereby authorize representatives of this city to enter upon the above-
mentioned property for inspection purposes.
C �ZV" 2�( Signature (Applicant or Agent):
STATE OF CALICORNIA .
ALTERATIONS - HVAC
CEC-CFIR-ALT-04-E Revised 06/14 CALIFORNIA ENERGY COMMISSION
CERTIFICATE OF COMPLIANCE CFIR-ALT-04-E
Alterations - HVAC CZ 2, and 8-15 (formerly CF -1R -ALT -HVAC) (Page 1 of 1)
Site Address: 55 q9
I
Enforcement Agency:
Date Prepared:
Permit#:
7- ad
\ I C��
v(�n ICG 6(2253
Equipment Type
Equipment Efficie y
New Ducting, Plenums, Lineset:
Conditioned
Ther ostat
Required R -value '
Floor Area (sq ft)
❑ Packaged System
❑ Evaporator Coil
2DAFUE
COP
❑ R-6 (CZ 2, 8-13) Ducting
Served by system
Setback
Split System
❑ Condensing Unit
❑ R-8' (CZ 11, 14, 15) Ducting
sgft
(if not already
❑ Mini Split
❑ Compressor
SEER
HSPFpresent
❑ R-6 (all CZ's) Plenums
must
❑ Furnace
11 Lineset
J'�EER
❑ R-5 or R7.5) Lineset°
be installed)
❑ TXV
HERS VERIFICATION SUMMARY Installer determines work to be completed and matches to one of the options below. At permit application this
fo is allowed to be filled out by hand. For final inspection all forms are to be registered (no hand filled forms allowed) and a copy left on site.
1. HVAC Changeout/Repair
Required Compliance Documents to be left on site for Final:
All Equipment,
CFIR-ALT-02-E
Condenser Unit, Evaporator Coil,
CF2R: MECH-01, MECH-20-HERS, MECH-(23 or 24)2_ HERS, MECH-25-HERS2
Compressor, TXV, Lineset,
CF3R: MECH-20-HERS, MECH-(23 or 24)-HERS2, MECH-25-HERS2
Air Handler/Furnace2 (Can include new ducting)
Installer Requirement: Duct leakage L15%, or < 10% to outside, or seal all accessible leaks), Air Flow ;-> 300 CFM/ton, Refrigerant Charge.
Exempted from duct leakage testing if:
❑ 1. Duct system registered with HERS provider as previously sealed, or ❑ 2. There is less than 40 linear feet of duct in unconditioned space, or
❑ 3. Existing dud systems a nstructed, insulated or sealed with asbestos (list manufacture date of building
2. New HVAC System N D Required Compliance Documents to be left on site for Final:
All new equipment and N ucts3 CFIR-ALT-02-E
including Mini Split CF2R: MECH-01, MECH-20-HERS, MECH-22-HERS, MECH-(23 or 24)-HERS2, MECH-25-HERS2
CF3R: MECH-20-HERS, MECH-22-HERS, MECH-(23 or 24)-HERS2, MECH-25-HERS2
Mini Splits require CFIR-ALT-02-E, CF2R-MECH-01, and (CF2R-CF3R) MECH-25-HERS
Installer Requirement: Duct leakage < 6%, Fan Efficacy (.58W/CFM), Air Flow >_ 350 CFM/ton (or alternative), Refrigerant Charge
113. All New Ducts with Replacement Required Compliance Documents to be left on site for Final:
All New Ducts' and one or more of the following CFIR-ALT-02-E
replaced: Condenser Unit, Evaporator Coil, CF2R: MECH-01, MECH-20-HERS, MECH-(23 or 24) -HERS, MECH-25-HERS
Compressor, TXV, Lineset, Furnace CF3R: MECH-20-HERS, MECH-(23 or 24) -HERS, MECH-25-HERS
Installer Requirement: Duct leakage < 6%, Air Flow >_ 350 CFM/ton (or alternative), Refrigerant Charge
Exempted from duct leakage testing if: ❑ 1. Existing duct systems are constructed, insulated or sealed with asbestos
❑ 4. New Ducting over 40 feet Required Compliance Documents to be left on site for Final:
New ducting but less than All New Duds' CF1R-ALT-02-E, CF2R: MECH-20-HERS, CF3R: MECH-20-HERS
Installer Required to: Duct leakage (:<_15% or, < 10% to outside or, or seal all accessible leaks)
- ❑ EXCEPTION: Existing duct systems constructed, insulated or sealed with asbestos.
' All new ducting R-8 required when more than 40 ft installed and R-6 when less than 40 ft installed. This includes in walls, between floors etc.
2 Heating only systems and Air Handler/Furnace changes do not require Air Flow MECH-(23 or 24), or Refrigerant Charge verification MECH-25
3 All New Ducts is when at least 75 percent of the duct system is new duct material, and up to 25 percent may consist of reused parts from the
dwelling unit's existing duct system (e.g., registers, grilles, boots, air handler, coil, plenums, duct material)
° R-5 (1" thick insulation) for linesets 1" and less. R-7.5 (1.5" thick insulation) for linesets over 1 inch. Most mfg will require Suction line Diameter
with insulation as the following 1.5-2T.-2%", 2.5 -3T -2W', 3.5 to 4T -27/a", 5T-4'/"
Contractor (Documentation Author's /Responsible Designer's Declaration Statement)
I certify the following under penalty of perjury, under the laws of the State of California:
1. The information provided on this Certificate of Compliance is true and correct.
2. 1 am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the information on this document.
3. That the energy features and performance specifications for the design identified on this Certificate of Compliance conform to the
requirements of Title 24, Parts 1 and 6 of the California Code of Regulations (CCR).
4. That the energy features and performance spocifications,'materials, components, and manufactured devices for the building design or
system design identified on this Certificate of Compliance conform to the requirements of Title 24, Part 1 and Part 6 of the CCR.
5. The building design features or system design features identified on this Certificate of Compliance are consistent with the information
provided on other applicable compliance documents, worksheets, calculations, plans and specifications submitted to the enforcement
agency for approval with this building permit application. .
Responsible Designer Name:
Rg�porisibl7. gner Sign lure:
Date Signed:
License:
vw,
//
�{ � 2d • 20
I.
V � Z O
Company.
ddr ss: 12 3L( S "wN�11
City/State/Zip:
Phone:
2038
p }-. oZ
(t 11,-)
For assistance or questions regarding the Energy Standards, contact the Energy Hotline at: 1-800=772-3300
FINANCIAL
DESCRIPTION ACCOUNT QTY';-,
AMOUNT PAID PAID DATE
BSAS SB1473 FEE 101-0000-20306 0
$1.00 $0.00
PAID BY METHOD', RECEIPT # CHECK # CLTD BY
Total Paid forBUILDING STANDARDS ADMINISTRATION BSA $1.00 $0.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
PAID
PAID DATE
HVAC CHANGEOUT - SPLIT -SYSTEM
101-0000-42402
0
$72.52
$0.00
PAID BY
METHOD
RECEIPT #
CHECK #
CLTD BY
DESCRIPTION
ACCOUNT
QTY
AMOUNT
PAID
PAID DATE
HVAC CHANGEOUT - SPLIT -SYSTEM PC
101-0000-42600
0
$36.26
$0.00
PAID BY
METHOD
RECEIPT #
CHECK #
CLTD BY
Total Paid forCHANGEOUT: $108.78 $0.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
PAID
PAID DATE
PERMIT ISSUANCE
101-0000-42404
0
$91.85
$0.00
PAID BY
METHOD
r RECEIPT #
CHECK #
CLTD BY
Total Paid for PERMIT ISSUANCE: $91.85 $0.00
TOTALS:0•
Description: SKIP SVESTA REPALCE 3.5 TON SPLIT SYSTEM
Type: MECHANICAL Subtype: Status: UNDER REVIEW
Applied: 4/20/2015 PJU
Approved:
Parcel No: 775181074 Site Address: 55492 LAUREL VALLEY LA QUINTA,CA 92253
Subdivision: TR 25500-1 Block: Lot: S
Issued:
Lot Sq Ft: 0 Building Sq Ft: 0 Zoning:
Finaled:
Valuation: $4,000.00 Occupancy Type: Construction Type:
Expired:
No. Buildings: 0 No. Stories: 0 No. Unites: 0
Details: REPLACE 3.5 TON SPLIT SYSTEM FURNACE EVAPORATION COIL AND CONDENSOR 80 % AFUE 14.5 SEER 12 EER PER 2013 MECHANICAL
CODES 2013 ENERGY] CARBON MONOXIDE ALARM(S) TO BE INSTALLED PRIOR TO FINAL INSPECTION.
FINANCIAL INFORMATION
Printed: Monday, April 20, 2015 11:38:36 AM 1 of 2 CRWYSTEMs
ADDITIONAL
CHRONOLOGY
CONDITIONS
ZIP„ PHONE • FAX EMAIL
CONTACTS
NAME TYPE NAME ADDRESSI•. ', CITY
STATE
APPLICANT
RAY'S AIR CONDITIONING AND HEA
OUTSIDE CITY LIMITS
LA QUINTA
CA
92253
CONTRACTOR
RAY'S AIR CONDITIONING AND HEA
OUTSIDE CITY LIMITS
LA QUINTA
CA
92253
OWNER
SVESTKA, ERWIN J
55492 LAUREL VALLEY
LA QUINTA
CA
92253
FINANCIAL INFORMATION
Printed: Monday, April 20, 2015 11:38:36 AM 1 of 2 CRWYSTEMs
REVIEWS
REVIEW TYPE REVIEWER SENT DATE DUE DATE RETURNED STATU7_7 REMARKS NOTES
DATE
Printed: Monday, April 20, 2015 11:38:36 AM 2 of 2 CRWsrsrEMS
INSPECTIONS
SEQID INSPECTION TYPE INSPECTOR SCHEDULED COMPLETED
DATE DATE
RESULT REMARKS NOTES
MECHANICAL FINAL" BLD
CLTD
DESCRIPTION'
ACCOUNT
QTY
AMOUNT
PAID
PAID DATE
RECEIPT #
CHECK #
METHOD
PAID BY
BY
RAY'S AIR
BSAS SB1473 FEE
101-0000-20306
0
$1.00
$1.00
4/20/15
MR152
DEBIT
CONDITIONING AND
PJU
HEA
Total Paid for BUILDING STANDARDS ADMINISTRATION
$1.00 $1.00
BSA:
RAY'S AIR
HVAC CHANGEOUT -
101-0000-42402
0
$72.52
$72.52
4/20/15
MR152
DEBIT
CONDITIONING AND
PJU
SPLIT -SYSTEM
HEA
RAY'S AIR
HVAC CHANGEOUT -
101-0000-42600
0
$36.26
$36.26
4/20/15
MR152
DEBIT
CONDITIONING AND
PJU
SPLIT -SYSTEM PC
HEA
Total Paid forCHANGEOUT: $108.78 $108.78
RAY'S AIR
PERMIT ISSUANCE
101-0000-42404
0
$91.85
$91.85
4/20/15
MR152
DEBIT
CONDITIONING AND
PJU
HEA
Total Paid forPERMIT ISSUANCE: $91.85 $91.85
TOTALS:
REVIEWS
REVIEW TYPE REVIEWER SENT DATE DUE DATE RETURNED STATU7_7 REMARKS NOTES
DATE
Printed: Monday, April 20, 2015 11:38:36 AM 2 of 2 CRWsrsrEMS
INSPECTIONS
SEQID INSPECTION TYPE INSPECTOR SCHEDULED COMPLETED
DATE DATE
RESULT REMARKS NOTES
MECHANICAL FINAL" BLD
REVIEWS
REVIEW TYPE REVIEWER SENT DATE DUE DATE RETURNED STATU7_7 REMARKS NOTES
DATE
Printed: Monday, April 20, 2015 11:38:36 AM 2 of 2 CRWsrsrEMS
Page 1 of 1
r
http://laquinta.crw.com/trakit9/OpenPDF.aspx?&report=/Documents/PERMITS/Permit De... 4/20/2015
Din #
-City of La Quinta
Building &r Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012.
Building Permit Application and Tracking Sheet
Permit #
Project Address:�Owner'sNae:
t e SV t'S f
A. P. Number: s— —
Address:5-Q Z
Legal. Description: Ye g
City, ST, Zip:I L U IK T 2 Z_ 3
Contractor Its VQ
�.
Telephone: -
Address: '1`i 7� S 26
Project Description:
n
City, ST, Zip: ?9 o, J/ 2 S•2(�
e� I 2j'' GV\
Telephone: v
P m 202- '-1-1 3 1
C
.............:.
Y L
�V ti •Y o
C.� 4 4 e C
State Lic. #
City Lic. #;
Arch., Engr., Designer:v
C Wc,-(
Address:
City., ST, Zip:
h:«LTelephone: :<:.»:'•'»+i>i<i»i ;i>i:
>
Constructioi n Type: Occupancy:
State Lic. #:
Project type circle one): New Add'n Alter
Repair Demo:
Name of Contact Person:Sq.
Ft:
#Stories:
# Units:
Telephone # of Contact Person:
o�
Estimated Value of Project: 15
APPLICANT: DO NOT WRITE BELOW THIS LINE
N
Submittal
Req'd
Rec'd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Cafes.
Called Contact Person
Plan Check Balance
Title 24 Calcs.
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.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
7rd Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees .
1% C
t b��
DESCRIPTION,
ACCOUNT
QTY
AMOUNT
PAID'
PAID DATE
RFCEIPT #
`- CHECK #
METHOD
PAID BY
CLTD
BY.
RAY'S AIR
BSAS SB1473 FEE
101-0000-20306
0
$1.00
$1.00
4/20/15
MR152
DEBIT
CONDITIONING AND
PJU
HEA
Total Paid forBUILDING STANDARDS ADMINISTRATION
$1.00 $1.00
BSA:
HVAC CHANGEOUT -
RAY'S AIR
101-0000-42402
0
$72.52
$72.52
4/20/15
MR152
DEBIT
CONDITIONING AND
PJU
SPLIT -SYSTEM
HEA
HVAC CHANGEOUT -
RAY'S AIR
101-0000-42600
0
$36.26
$36.26
4/20/15
MR152
DEBIT
CONDITIONING AND
PJU
SPLIT -SYSTEM PC
HEA
Total Paid forCHANGEOUT: $108.78 $108.78
RAY'S AIR
PERMIT ISSUANCE
101-0000-42404
0
$91.85
$91.85
4/20/15
MR152
DEBIT
CONDITIONING AND
PJU
•
HEA
Total Paid for PERMIT ISSUANCE: $91.85 $91.85
TOTALS:
INSPECTIONS
SEQID INSPECTION TYPE INSPECTOR SCHEDULED COMPLETED RESULT REMARKS NOTES
DATE DATE: .
MECHANICAL FINAL" BLD
Printed: Monday, April 20, 2015 11:38:36 AM 2 of 2 C#?srsTEMS
Description: SKIP SVESTA REPALCE 3.5 TON SPLIT SYSTEM
Type: MECHANICAL Subtype: Status: UNDER REVIEW
Applied: 4/20/2015 PJU
Approved:
Parcel No: 775181074 Site Address: 55492 LAUREL VALLEY LA QUINTA,CA 92253
Subdivision: TR 25500-1 Block: Lot: 5
Issued:
Lot Scl Ft: 0 Building Sq Ft: 0 Zoning:
Finaled:
Valuation: $4,000.00 Occupancy Type: Construction Type:
Expired:
No. Buildings: 0 No. Stories: 0 No. Unites: 0
ZIP PHONE FAX
Details: REPLACE 3.5 TON SPLIT SYSTEM FURNACE EVAPORATION COIL AND CONDENSOR 80 % AFUE 14.5 SEER 12 EER PER 2013 MECHANICAL
CODES 2013 ENERGY] CARBON MONOXIDE ALARM(S) TO BE INSTALLED PRIOR TO FINAL INSPECTION.
FINANCIAL INFORMATION
Printed: Monday, April 20, 2015 11:38:36 AM 1 of 2 V?srsrEMs
CONTACTS
NAME TYPE •
NAME
ADDRESSI
CITY
STATE
ZIP PHONE FAX
EMAIL
APPLICANT
RAY'S AIR CONDITIONING AND HEA
OUTSIDE CITY LIMITS
LA QUINTA
CA
92253
CONTRACTOR
RAY'S AIR CONDITIONING AND HEA
OUTSIDE CITY LIMITS
LA QUINTA
CA
92253
OWNER
SVESTKA, ERWIN J
55492 LAUREL VALLEY
LA QUINTA
CA
92253
FINANCIAL INFORMATION
Printed: Monday, April 20, 2015 11:38:36 AM 1 of 2 V?srsrEMs
k v
DESCRIPTION
FINANCIAL INFORMATION
ACCOUNT
QTY
AMOUNT ,
PAID.-
PAID DATE
BSAS SB1473 FEE
101-0000-20306
0
$1.00
$0.00
PAID.BY
METHOD
' RECEIPT #
CHECK #
CLTD BY
Total Paid forBUILDING STANDARDS ADMINISTRATION BSA $1.00 $0.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
'PAID
PAID DATE
HVAC CHANGEOUT - SPLIT -SYSTEM
101-0000-42402
0
$72.52
$0.00
PAID'BY „
' METHOD '_
RECEIPT.#
CHECK #
CLTD BY
DESCRIPTION
ACCOUNT .
QTY
AMOUNT
PAID.
PAID DATE
HVAC CHANGEOUT - SPLIT -SYSTEM PC
101-0000-42600
0
$36.26
$0.00
PAID BY '`
METHOD �_.
RECEIPT # , .:.
CHECK #
CLTD BY.
Total Paid forCHANGEOUT: $108.78 $0.00
DESCRIPTION -
.ACCOUNT
QTY
AMOUNT
PAID _
PAID DATE
PERMIT ISSUANCE
101-0000-42404
0
$91.85
$0.00
? ' PAID.BY
METHOD
RECEIPT #
CHECK #
CLTD BY
Total Paid for PERMIT ISSUANCE: $91.85 $0.00
TOTALS:00
k v
' 4auu,t,1'iw VOICE (760) 777-7125
78-495 CALLE TAMPICO D 4 fAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 COMMUNITY DEVELOPMENT DEPARTMENT INSPECTIONS (760) 777-7153
'SCS6®ILDING PERMIT
ISSUED Date: 4/20/2015
Application Number: BMCH2O15-0136 Owner:
Property Address: 55492 LAUREL VALLEY APR 2 01015 SVESTKA, ERWIN J
APN: 775181074 55492 LAUREL VALLEY
Application Description: SKIP SVESTA REPALCE 3.5 TON SPLIT SYSTEM LA QUINTA, CA 92253
Property Zoning:
Application Valuation: $4,000.00 ,
Applicant:
RAY'S AIR CONDITIONING AND HEA
OUTSIDE CITY LIMITS
LA QUINTA, CA 92253
APR 2 0 2015
CITY OF LA OUINTP
COMMUNITY DEVELOPMENT OEPAPT! LENT
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: License No.: :LIC -0111472
)(Date: G iO , 7,o(;�P;— Contractor:
OWNER -BUILD R D LARATION
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
permit subjects the applicant to a civil penalty of not more than five hundred dollars
($500).:
I ) 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 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 Address:
Contractor:
RAY'S AIR CONDITIONING AND HEA
OUTSIDE CITY LIMITS
LA QUINTA, CA 92253
(760)202-7770
Llc. No.::LIC-0111472
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 polity number are:
Carrier:_ Policy Number: _
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.
mate: �' Zd. Applicant:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE I NLAWFUL,
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 3106 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 building
construction, and hereby authorize representatives of this city to enter upon the above•
mentioned property for inspection purposes.
'Ete: �ZV " 2�( Signature (Applicant or Agent):