12-1190 (RER)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Ta�/440"
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Application Number: ,12-0 0 0 011 90
Property Address: 50095 DORAL ST
APN: 770-070-018-56 -25389 -
Application description: REMODEL - RESIDENTIAL
Property Zoning: MEDIUM DENSITY RES
Application valuation: 600
Applicant: K) Architect or Engineer:
ala
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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 Professional Code, and my License is in full force and effect.
License Class: B icense No.: 909823
D t Z C tractor:
OWNER -BUILDER DECLARATION
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 a permit subjects the applicant to a civil penalty of not more than five hundred dollars 155001•:
(_ 1 1, 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
work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name:
Lender's Address:
LQPERMIT
ofIhe GOT 0
Owner:
LINDSTROM
50095 DORAL STREET
LA QUINTA, CA 92253
Contractor:
3 BIC INC
PO BOX 1401
PALM DESERT, CA 92260
(760)578-4300
Lic. No.: 909823
VOICE (760) 77e
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 10/08/12
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 E} EMPT Policy Number EXEMPT
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 L Code, I all forth i comply
with those provisions.
/: 4T Applican
WARNING: FAI URE TO SECURE WORKERS' COMPE SATION with
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 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 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
Ithal
d under or following issuance of this permit.
mit issued as a result of this application becomes null and void if work is not commenced
60 days from date of issuance of such permit, or cessation of work for 180 days will subject
o cancellation.
ead this application and state that the above infor tion is correct. I agree to comply with all
ances and state laws relating to building constr tion, reby authorize representatives
er port the above-mentioned insp ion u es.
Signature (Applicant or Agent):
Application Number . . . . . 12-00001190
Permit . . .
BUILDING PERMIT
Additional desc .
Permit Fee . . . .
17.00 Plan Check Fee
11.05
Issue Date . . . .
Valuation . . .
. 600
Expiration Date
4/06/13
Qty Unit Charge
Per
Extension
BASE FEE
15.00
1.00 2.0000
HND BLDG 501-2,000
2.00
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Special Notes and Comments
REMOVE AND REPLACE -
25 L.F DRY WALL IN
BATHROOM DUE TO WATER
DAMAGE. 2010
CODES.
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Other Fees . . . .
. . . . BLDG STDS ADMIN (SB1473)
1.00
Fee summary Charged Paid Credited
-----------------
Due
----------
Permit Fee Total
------------------------------
17.00 .00 00
17.00
Plan Check Total
11.05 .00 .00
11.05
Other Fee Total
1.00 .00 .00
1.00
Grand Total
29.05 .00 .00
29.05
LQPERMIT
i
Bin.#
CJty. of La Quinta �
.
Building a Safety Division
Perinit # qo.
P.O. Box 1504,78-495 Calle Tampico
ia.Quinta, CA 92253 - (760) 777-7012 (rlAj2S
Building Permit'Application and Tracking Sheet
ProjectAddress:
Owner's Name:.
A P. Number.
Address: 0
j Legal Description:
City, ST, Zip:
Contractor. — t
Telephone: 42stoGu
Address:k (
_.rn EnCity,
Project Description:
ST, Zip:
i Telephone:
State Lie. # :
City Lia fE:
Arch., Engr., Designer.
Address:
City., ST, Zip:
Telephone:
^:� w ' ' ° Construction type: Occupancy:
i State Lie. #:
Project type (circle one): New Add'n Alter Repair Demo
Name of Contact Person:
Sq. Ft.: # Stories: # Units:
':. Telephone # of Contact Person:Estimated
Value of Proj (000
i
APPLICANT: DO NOT WRITE BELOW THIS LINE
# Submittal Req'd Recd TRACMG PERMIT FEES
Plan Sets
Plan Check submitted Item Amount
Strgctural Cates.
Reviewed, ready for corrections Plan Check Deposit. .
Truss Calcs•
Called Contact Person Plan Check Balance
Titre 24 Calcs.
Plans picked up Construction '
Flood plaiaplan _
_P.lads.cesubmitted 4.
Grading plan
2`+ Review, readyfor correcGonsfissue
Electrical
Subcoatector List
Called Contact Person
Plumbin
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN ROUSE:-
'^' RcAcw� ready for correctionsfissue
Developer Impact Fee
Planning Approval.
Called Contact Person
AJ.P.P.
Pub. Wks. Appr '
Date of permit issue
School Fees
Total Permit Fees