12-1058 (PAT)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: 12-00001058
Property Address: 78615 FORBES CIR
APN: 604-223-003-46 -23268 -
Application description: PATIO COVER - RESIDENTIAL
Property Zoning: LOW DENSITY RESIDENTIAL
Application valuation: 5027
Til`!t 4 4 Q"
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Applicant: Architect or Engineer:
DIP/
--------------------------------------------
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that 1 am licensed u de provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professio ode, and my License is in full force and effect.
License Class: ,C33 C51 ! /L' enseNo.: 855623
Date: / / ntractor:
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 ($500).:
1 _ 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.).
1 1 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:
MIKE MACDORMICK
78615 FORBES CIRCLE
LA QUINTA, CA 92253
Contractor:
GOLD STAR CSTM PTG LQ PATIO CO
42335 WASHINGTON ST #F363
PALM DESERT, CA 92211
(760)574-1043
LiC. No.: 855623
VOICE (760) 77-70
FAX (760) 7 - 11
SONS (760) 777-7153
9/17/12
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 PREFERRED EMPLR Policy Number WKN1438262
_ 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, k9hall
forthwith com lyyww thse provisions.
De: pplicant:�i�—
WARNING: FAILURE TO SECURE WORKERS' 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 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
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 auth 'ie representatives
of this county to enter upon the above-mentioned pr partyZfori ection purposes.
Date: / % ' ignature (Applicant or Agentl:
Application Number . . . . . 12-00001058
Permit . .
. PATIO COVER PERMIT
Additional desc .
.
Permit Fee . . .
. 81.00 Plan Check Fee
52.65
Issue Date
Valuation
5027
Expiration Date
3/16/13
Qty Unit Charge Per
Extension
BASE FEE
45.00
4.00 9.0000 THOU BLDG 2,001-25,000
36.00
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Special Notes and
Comments
378 S.F. SOLID ALUMAWOOD PATIO COVER.
2010 CODES.
----------------------------------------------------------------------------
Other Fees . . .
. . . . . . BLDG STDS ADMIN (SB1473)
1.00
STRONG MOTION (SMI) - RES
.50
Fee summary
-----------------
Charged Paid Credited
----------------------------------------
Due
Permit Fee Total
81.00 .00 .00
81.00
Plan Check Total
52.65 .00 .00
52.65
Other Fee Total
1.50 .00 .00
1:50
Grand Total
135.15 .00 .00
135.15
LQPERMIT
olTY OF LA QUINT A
JILDING & SAFETY DEFT.
APPROVE®
FOR CONSTRUCTION
TE -q- 171
Kim
1�
C.
City of La Quints
:Bai(ftarSafety Divis l
P.O. Box 1504,•78-49S Cage Tampico
4.Qdzta, CA 92253-.-(760) 777-7012
Buitdin g Permit Application'and Tracking Sheet
Perinit # 'Gk /
p
'
Reject Address: 7 5'
—I
Owner's Name:. f � G / d(�
Address 'I�pPs S4-
4Legg
A P. Number
Leggtion:
City. ST, Zip:
Contractor. � � � ��q-
Telephone:
Address. 'j Qrs — #
e Description:
City. ST, Zip: �1�Pk : ZZ I
B t/ay-,�
Telephone 766 5-7&/,/0
ArdL. Eng, Iia: "
Address.
Cit}!. ST, Zip:
TeIephoae:
Stato Lir. - _
Construction Type:. OccvPancy:
Prayedtype (Cade one): . ew Add'a Alter Repair Demo
Sq. Ft : �� St��njjrie� # Utut
Name of Contact Penson
Tclephone 0 of Coact Person:
EstimatW Value of ProjectIA5 20-17
APPLICANT: DO NOT WRITE BELOW TMS LINE
p Sabimitw ReWd Recd 'IRACKWO PERMfrFM-
Plga Sets
Pian Cheek submitted Item Amount
Structural Calca.
Reviewed, ready for corrections Plan Check Deposit. .
MrM Cala.
Called Contact Person Plan Cheek Balance-
,not 24 Cates.
Plans pithcd up Construction
Flood plain plan
Plans rtsubmitted.' . Mechanical
Grading pian
Z`! Review. ready for correeflonsrrave Electrical
Subeostaotor List
Called ContactPerson Plnmbiag
Grant Deed
Plans picked up S.MJL
ILO-A. Approval
Plans resubmitted Gradtng
10 HOUSB:-
3" Review; ready for cormcdo'nsrtssme Devdoper Impact Fee
Planning Approval-
Called Contact Pawn A".P.
Pub. Vim Appr
Date of permit issue
School Fees "
Total Permit Fees