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BPLB2016-0049LICENSED 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. Licensee CClass: C�(36, A. C33, C10 License .: 936147 Date:. / -2 1 _ 1 (19Contractor: //V)®- L/I 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 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 7on rk for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Se700 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 Section37Q0 of the Labor Code, I shall forthwith comply with those provisions. Date:.)- I Applicant;. / / r � ( / permit subjects the applicant to a civil penalty of not more than five hundred dollars WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 15 UNLAWFUL, ($500).: AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ( ) 1, as owner of the property, or my employees with wages as their sole ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF compensation, will do the work, and the structure is not intended or offered for sale. COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, (Sec. 7044, Business and Professions Code: The Contractors' State License Law does not INTEREST, AND ATTORNEY'S FEES. 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 Name: Lender's Address: 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 cit enter upon the above-mentioned property for inspection purposes. Date: ��/ /�ignature (Applicant or Agent 18 VOICE (760) 777-7125 78-495 CALLE TAMPICO �;;.;.;. U FAX FAX (760) 777-7011 LA QUINTA, CALIFORNIA 92253 COMMUNITY DEVELOPMENT DEPARTMENT (760) 777-7153 • BUILDING PERMIT Date: 3/21/2016 Application Number: BPLB2016-0049 Owner: Property Address: 51565 AVENIDA RAMIREZ ALBIN SECOND FAMILY LTD PART APN: 773125016 1403 GARFIELD AVE Application Description: WAGNER / CHANGE OUT (1) 40GALLON GAS WATERHEATER SOUTH PASADENA, CA 92253 C", Property Zoning: Application Valuation: $900.00 z o0FPt;"- Applicant: Contractor: _Q STATEWIDE SERVICES INC DBA STATE WIDE PL STATEWIDE SERVICES INC DBA STA RID 36947 COOK ST STE 104 m 36947 COOK ST STE 104 rn C PALM DESERT, CA 9211 PALM DESERT, CA 9211 a O (442)666-8858 m Llc. No.: 936147 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. Licensee CClass: C�(36, A. C33, C10 License .: 936147 Date:. / -2 1 _ 1 (19Contractor: //V)®- L/I 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 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 7on rk for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Se700 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 Section37Q0 of the Labor Code, I shall forthwith comply with those provisions. Date:.)- I Applicant;. / / r � ( / permit subjects the applicant to a civil penalty of not more than five hundred dollars WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 15 UNLAWFUL, ($500).: AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ( ) 1, as owner of the property, or my employees with wages as their sole ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF compensation, will do the work, and the structure is not intended or offered for sale. COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, (Sec. 7044, Business and Professions Code: The Contractors' State License Law does not INTEREST, AND ATTORNEY'S FEES. 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 Name: Lender's Address: 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 cit enter upon the above-mentioned property for inspection purposes. Date: ��/ /�ignature (Applicant or Agent FINANCIAL INFORMATION DESCRIPTION '.; ACCOUNT ` :. QTYl '",.-AMOUNT: 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 t . METHOD RECEIPT #, - ` x; ' CHECK # CLTD BY. Total Paid for PERMIT ISSUANCE: $91.85 $0.00 DESCRIPTION ACCOUNT x : , QTY�� AMOUNT,' �. PAID PAIDDATE WATER HEATER/VENT 101-0000-42401 0 $12.09 $0.00 PAID BY "METHOD .,,,.:,RECEIPT, # 'CHECK #, . = CLTD BY' DESCRIPTION, 'ACCOUNT : :` . . QTY'. , 'AMOUNT, PAID-. "PAID DATE WATER HEATER/VENT PC 101-0000-42600 0' . $7.25 $0.00 PAID BY - `METHOD- " RECEIPT # . CHECK # _ CLTD BY., " Total Paid for PLUMBING FEES: $19.34 $0.00 TOTALS:•• Description: WAGNER / CHANGE OUT (1) 40GALLON GAS WATERHEATER Type: PLUMBING Subtype: Status: UNDER REVIEW Applied: 3/21/2016 SKH Approved: Parcel No: 773125016 Site Address: 51565 AVENIDA RAMIREZ LA QUINTA,CA 92253 Subdivision: SANTA CARMELITA VALE LA QUINTA Block: 5S Lot: 4 Issued: UNIT 5 Lot Scl Ft: 0 Building Sq Ft: 0 Zoning: Finaled: Valuation: $900.00 Occupancy Type: Construction Type: Expired: No. Buildings: 0 No. Stories: 0 No. Unites: 0 ADDRESSI Details: WATER HEATER CHANGE OUT - 40GALLON/GAS [2013 ENERGY] CARBON MONOXIDE ALARM(S) TO BE INSTALLED PRIOR TO FINAL INSPECTION. 2013 CALIFORNIA BUILDING CODES. CHRONOLOGY CONDITIONS CONTACTS NAME TYPE NAME ADDRESSI CITY STATE ZIP PHONE FAX EMAIL APPLICANT STATEWIDE SERVICES INC DBA STATE 36947 COOK ST STE 104 PALM DESERT CA 9211 STATEWIDEPLUMBING WIDE PL 2010@YAHOO.COM CONTRACTOR STATEWIDE SERVICES INC DBA STATE 36947 COOK ST STE 104 PALM DESERT CA 9211 STATEWIDEPLUMBING WIDE PL I 2010@YAHOO.COM OWNER ALBIN SECOND FAMILY LTD PART 1403 GARFIELD AVE SOUTH CA 92253 PASADENA Printed: Monday, March 21, 2016 11:48:24 AM 1 of 2 SYSTEMS BOND INFORMATION Printed: Monday, March 21, 2016 11:48:24 AM 2 of 2 Or SYSTEMS CLTD DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE RECEIPT # CHECK # METHOD PAID BY BY 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 WATER HEATER/VENT 101-0000-42401 0 $12.09 $0.00 WATER HEATER/VENT 101-0000-42600 0 $7.25 $0.00 PC Total Paid for PLUMBING FEES: $19.34 $0.00 BOND INFORMATION Printed: Monday, March 21, 2016 11:48:24 AM 2 of 2 Or SYSTEMS l-PrAcrip ive-Certificate of Compliance: Residentil;J CF-IR--kLT-DH.w- � Residential Alterafionls Pmiect Name: imZone: j Permit Ir: Clate WATER HEATING List neurit• installed water heaters and boilers for built doinestie hot mater heaters (DWH) and !tt4ronic space kneeing. DtYH heaters and boi[&s must be gas. propane. or use the e ristin "gel rs Nek4. install rd Water Heater Typd'Fstd Type, Distribution _ Factor NumbLT In Tarek Energy R $ 1' system Capacity (gal) Tbcmul Efficicrcy Extcrtut Tank Insulatioa R -Value' i . I t, indicate Type (Storage Gas. Heat Pump; Instantancous. ctc.J 2. Recirculating systeins serving multiple dwriling units shall inert the recirculation regLdretnenrs of §1500). The Prescriptive requirements do notaliow the inuallation of a recirculating waterheating stsrem for single dwelling units. 3. The etternal water heating tank and p4pes shall be insulated to meet th>- rrquiren-ews of §! ). Contmctor or Romeowner (Documentation Author's/Responsibte Building Designer's D}edaration Statement) • I certify that this Certificate of Compliattc-c documentation is accu atc and complete. • I am eligible under Division 3 of the Califonlia Business arta Pmfessiotis Code to accent responsibility for the building design identified on this Certifx=e of Compliance. • I certify that the en«gy features and performance specifications for the building design iderWfy.A on this Certificate of Compliance conform to the requirements of Title 24. Pact I and 6 of the California Code of Regulations. . 'lite building design features identifted on this Cectificte of Corripiiar= art consistmt with the information provided to document this building design on the other applicable compliance forms., work*&-- s_ �^ularorrs pla-rts and specifreaitons submitted to the enforcement agency for aootoeal with this bti.►dine oerrnk aooltcati A �d�-I Bin # City of La Quanta Building BT Safety Division P.O. Box 1504, 78-495 Calle Tampico Permit # La Quinta, CA 92253 - (760) 777-7012 'Y2 �,t (O J Building Permit Application and Tracking Sheet Project Address: e Owner's Name: C621 In A. P. Number: Address. l t Legal Description: City, ST, Zip: t Contractor: �l P Telephone: Kill s Address: Project Description: City, ST, Zip: T C, Telephone• Q 171�17 ? State Lic. # : City Lic. #: Arch., Engr., Designer. Address: City., ST, Zip: Telephone: State Lic. # Name of Contact Person: M. �L„��•:`s; w��„•L', A�:<n..;:s:•,• s,., 'cs Kms' %''��'aX•-�•.M•r,,'_'.ct `r;gyz Construction Type: Occupancy: Project type (circle one): New Add'n Alter Repair Demo Sq. FL: n Stories:# Units: Telephone # of Contact Person: Estimated Value of Project: APPLICANT: DO NOT WRITE BELOW THIS LINE # Submittal Req'd Ree'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 Tide 24 Cates. 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 Pians resubmitted Grading IN HOUSE: '^' Review, ready for correctlonsfissue Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub. Wks. Appr I Date of permit issue School Fees Total Permit Fees