BPLB2016-004578-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
`may' °& 4 Q"
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING PERMIT
Application Number:
BPLB2016-0045
Property Address:
53661 AVENIDA MARTINEZ
APN:
774131020
Application Description:
FARROW /ABANDON SEPTIC/CONNECT TO SEWER
Property Zoning:
Application Valuation:
$3,000.00
Applicant:
EDWARD J STRZELCZYK
P 0 BOX 7114
LA QUINTA, CA 92248-7114
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: B C10 C29 License No.: 439904
Date: J X0 /`� Contractor:
OWNER -BUILDER DEC15 RATION
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).:
( ) 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.).
( ) 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
Lender's Address:
13
VOICE (760) 7774125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 3/10/2016
Owner:
STEPHEN FARROW
Contractor:
EDWARD J STRZELCZYK
P 0 BOX 7114
LA QUINTA, CA 92248-7114
(760)578-0201
Llc. No.: 439904
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:
Carr' Policy Number:
certify that in the performance of the work for which this permit is issued, I
s I not employ any person in any manner so as to become subject to the workers'
ompensawn 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:!1 �6 Applicant:
WARNING: F(LURE TO SECURE WORKERS' COPENSATION 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 this city to enter upon the
above-mentioned property -for inspection purposes.
Date: Z = /d Signature (Applicant or Agent):
FINANCIAL INFORMATION
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 for BUILDING STANDARDS ADMINISTRATION BSA: $1.00 $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
DESCRIPTION
ACCOUNT
QTY
AMOUNT
PAID
PAID DATE
SEPTIC SYSTEM
101-0000-42401
0
$12.09
$0.00
PAID BY
METHOD
RECEIPT#
CHECK #
CLTD BY
DESCRIPTION
ACCOUNT '; ..
QTY
AMOUNT
PAID
PAID DATE
SEPTIC SYSTEM PC
101-0000-42600
0
$4.83
$0.00
PAID BY
METHOD
RECEIPT #
CHECK #
CLTD BY
Total Paid for PLUMBING FEES: $16.92 $0.00
TOTALS:0• • 00
Description: FARROW /'ABANDON SEPTIC/CONNECT TO SEWER
CONDITIONS
Type: PLUMBING Subtype:
Status: UNDER REVIEW
Applied: 3/10/2016 SKH
Approved:
Parcel No: 774131020 Site Address: 53661 AVENIDA MARTINEZ LA QUINTA,CA 92253
Subdivision: SANTA CARMELITA VALE LA QUINTA Block: 244
Lot: 8
Issued:
UNIT 23
NAME TYPE
NAME
Lot Sq Ft: 0 Building Sq Ft: 0
Zoning:
Finaled:
Valuation: $3,000.00 Occupancy Type:
Construction Type:
Expired:
No. Buildings: 0 No. Stories: 0
No. Unites: 0
EDWARD J STRZELCZYK
Details: ABANDON SEPTIC/CONNECT TO SEWER. 2013 CALIFORNIA BUILDING CODES.
LA QUINTA
ADDITIONAL SITES
CHRONOLOGY
CONDITIONS
CONTACTS
NAME TYPE
NAME
ADDRESSI
CITY
STATE
ZIP
PHONE
FAX
EMAIL
APPLICANT
EDWARD J STRZELCZYK
P 0 BOX 7114
LA QUINTA
CA
92248-
7114
CONTRACTOR
EDWARD J STRZELCZYK
P 0 BOX 7114
LA QUINTA
CA
92248-
7114
OWNER
STEPHEN FARROW
Printed: Thursday, March 10, 2016 3:10:15 PM 1 of 2 CN?w
SYSTEMS
DESCRIPTION
ACCOUNT
CITY
AMOUNT
PAID
PAID DATE
RECEIPT #
CHECK #
METHOD
PAID BY
LTD
CBY
BSAS SB1473 FEE
101-0000-20306
0
$1.00
$0.00
Total Paid for BUILDING STANDARDS ADMINISTRATION
$1.00 $0.00
BSA:
PERMIT ISSUANCE
101-0000-42404
0
$91.85
$0.00
Total Paid for PERMIT ISSUANCE: $91.85 $0.00
SEPTIC SYSTEM
101-0000-42401
0
$12.09
$0.00
SEPTIC SYSTEM PC
101-0000-42600'
0
$4.83
$0.00
Total Paid for PLUMBING FEES: $16.92 $0.00
BOND INFORMATION
Printed: Thursday, March 10, 2016 3:10:15 PM 2 of 2
CB? -W- SYSTEMS
Qin #
Qty of 1,a Q uin to
Building 8t Safety Division
78 495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
Project Address:
Owner'sName: S vJ Apt-'
A. P. Number:
Address:
Legal Description:
City, ST, Zip;/,
Contractor: L / Z
TeleP hone:
Address:
Project Description:
City, ST, Zip: -
Teleh e.
P o n6 rJ Z 1
State Lie. # : p
City Lie. #;
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone:
an cY:
n TY Pe- Occupancy:
Construction
State Lie.#
Repairair
(circle one)�N w Add'n Alter
Demo
Name of Contact Person:
Sq. Ft.:
#Stories:
# Units:
Telephone # of Contact Person:
Estimated Value of Project:''
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rcc'd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance,
Title 24 Cales.
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 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
COACHEL LA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From:
Address:
Account No. _ �- - % Laos)
Service Address
O Meters)
O Service(a)
O Backflow(a)
O House Lateral(s)
Q DetectorCheck(s)
U Meter Surcharge I
J�ltatlon.CapacltyCharge
O. 'W.S.B.F.C.
O Temporary Construction. Motor, _
O Tum on,Chatpe -
L! Uncollected Accounl- Name
- (J Inspactlon Fee -Tract -
Fee - '
t ❑ Pian Check .Fees Water I Sewer -
Tract -
.O Bond Payment - A.D. - Bond
-Assmt:
n Customer Deposit
O Other
Aemarks:
�dCopy to: Ile,
�• _Cash .
ql
Money
Order
OFJ�J(�,1��
96903
Na 96903
Tract
G.A. Code
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