BSPN2016-001978-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Twit 4 4 Qumrcu
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING PERMIT
Application Number:
BSPN2016-0019
Property Address:
79180 CORPORATE CENTRE DR STE 101
APN:
600390013
Application Description:
SPECIAL INSPECTION / IBRAHIM SAMUEL
Property Zoning:
Application Valuation:
Applicant:
SAMUEL IBRAHIM
79180 CORPORATE CENTER DRIVE
LA QUINTA, CA 92253
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.:
Date:
Contractor:
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
Wm
00).:I,as owner of the property, or my employees with wages as their sole
pensation, 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.).
Cri I as owner of the property, am exclusively contracting with licensed contractors
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.).
�.V,_) 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:
11111111111111111111
12
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: .2/16/2016
Owner:
JAMES PAUL
55585 CHERRY HILLS
LA QUINTA, CA 92253
Contractor: 4 d
Llc. No.:
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
ensaI have and will maintain a certificate of consent to self -insure for workers'
com tion, 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 workers' compensation insurance carrier and polity number are:
Carrier: Policy Number
I certify that in the p ormance of the work for which this permit is issued, I
shaemploy 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 Sec:Z]X
, I shall forthwith
comply with those provisions.
Date: t Applicant:
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 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 thisy to enter upon the
above- jenntioined property for inspection purposes.
Date: `C ` Signature (Applicant or Agent):
FINANCIAL ••
•
DESCRIPTION
ACCOUNT
CITY AMOUNT
PAID
PAID DATE
SPECIAL INSPECTION
101-0000-42404
0 $72.52
$72.52
2/16/16
PAID BY
METHOD
RECEIPT #
CHECK #
CLTD BY
NHAT CANH NGUYEN- MINH MD INC
CHECK
R12911
1135
RSE
Total Paid for COMPLIANCE SURVEY/SPECIAL INSPECTION: $72.52 $72.52
Description: SPECIAL INSPECTION / IBRAHIM SAMUEL
Type: SPECIAL INSPECTION
Subtype:
Status: UNDER REVIEW
Applied: 2/16/2016 RSE
Approved:
Parcel No: 600390013 Site Address: 79180 CORPORATE CENTRE DR STE.101 LA QUINTA,CA
92253
Subdivision: PM 29351
Block:
Lot: 3
Issued:
Lot Sq Ft: 0
Building Sq Ft: 0
Zoning:
Finaled:
Valuation: $0.00
Occupancy Type:
Construction Type:
Expired:
No. Buildings: 0
No. Stories: 0
No. Unites: 0
Details:* SPECIAL INSPECTION FOE MEDICAL PRIVATE PRACTICE. THIS JOB CARD IS NOT FOR ANY WORK.
Printed: Tuesday, February 16, 2016 8:48:45 AM 1 of 2 'r C
SYSTEti1S
BOND INFORMATION
Printed: Tuesday, February 16, 2016 8:48:45 AM 2 of 2
SYSTEMS
Bin #
City of La Quinta
Building 8i: Safety Division
78-495 Calle. Tampico
La Quinta, CA 92253 - (760) 777-7012
00)1 Building Permit Application and Tracking Sheet
Permit #
20.1b
Project Address:_ cotpawb , -4
Owner's Name:
A. P. Number:
Address: 7 V4 Ceffnee
Legal Description:
City, ST, Zip: Lt- vu*ifa C- 921 '
Contractor: r.
Tele h e._4,b! 3q 6 3 i
Address:
Project Description:
City, ST, Zip:
Telephone:
State Lic. # :
City Lic. #;
Arch., Engr., Designer:
Address:
City., ST, Zip:
Telephone: hone:
Con tructi n Type: Occupancy:
State Lic. #
Project type'(circle New' Add n Alter Repairair Demo
Nameiof Contact Person:
Sq. Ft.:
# Stories:
# Units:
Telephone # of Contact Person:
Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rec'd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural CAM
Reviewed, ready for corrections
Plan Check Deposit
Truss Cates.
Called Contact Person
Plan Check Balance
Title 24'Calcs.
'Plans picked up
Construction '
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
tad 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 ROUSE:-
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