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BRES2015-026378-495 CALL LA QUINTA, Application Number:=— Property Address: APN: Application Description: Property Zoning: Application Valuation: Applicant: JOSEPH BIRDSELL P 0 BOX 630 LA QUINTA, CA 92247 I Qu Twyl 4 COMMUNITY DEVELOPMENT DEPARTMENT BUILDING PERMIT 49100 AVENIDA ANSELMO 658280005 LANGE / SINGLE FAMILY RESIDENCE / OLD PERMIT #AR -14-333 $206,661.20 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 f the Business and Professions Code, and my License is in full force and effect. \ License Class: B License No.: 811 93 Data/ r— — . Contra r OWNER-BUI DE E RATION I hereby affirm under penalty of perjury that I am empt 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, 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 VOICE (760) 777-7125 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 10/13/2015 Owner: ROBERT LANGE P 0 BOX 193 COCKEYSVILLE, MD 92253 Contractor: JOSEPH BIRDSELL P 0 BOX 630 LA QUINTA, CA 92247 (760)409-7070 Llc. No.: 811293 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 :)f the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' conpensation 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: _ Policy Number: _ I certify that in the performance of tke work for which this permit is issued, I shall not employ any person in any manner`\p as to become subject to the workers' compensation laws of California, and r e t t if I should become ubject to the workers' compensation provisions of ion 3�of the Labor Code, shall forthwith comply with those prrovisions. Dad/ �l App a / 1 WARNING: FAILURE TO SECURE WORK RS OIN PENSATION 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 N SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. APPLICANT ACKNOWILEDGEMENT IMPORTANT: Application is hereby made to theBuilding 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 isauance of such permit, or cessation of work for 180 days will subject permit to cancellation. 1 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 representat2ses of t ity to enter upon.the above-mentioned/ property for inspection purposes. n Date:` ` ` �' V Signature (Applicant or Age t) 'w J DESCRIPTION FINANCIAL INFORMATION ACCOUNT - _;,: QTY AMOUNT _ PAID ,," .EPAID:_DATE HOURLY CHARGE - BLDG CITY STAFF 101-0000-42600 2 $290.00 $290.00 10/13/15 PAID BY.. _ .: ;m ":.METHOD ": RECEIPT #. CHECK # CLTD BY. , OPUS BANK CHECK R9966 1211000077 MFA f ;DtkRI•0TION r ACCOUNT QTY, " AMOUNT PAID " PAID DATE HOURLY CHARGE - BLDG CITY STAFF 101-0000-42600 0.5 $72.50 $72.50 10/13/15 < PAID BY. METHOD ,RECEIPT # , 'CHECK # CLTD BY OPUS BANK CHECK R9966 1211000077 MFA DESCRIPTION r ACCOUNT,QTY < , < AMOUNT'' PAID PAID DATE. HOURLY PLAN CHECK - YES 101-0000-42600 3 $210.00 $210.00 10/13/15 PAID BY s METHOD RECEIPT # CHECK # CLTD BY.. OPUS BANK CHECK R9966 1211000077 MFA DESCRIPTION`, ACCOUNT qTY; :, AMOUNT PAID,-,.:PAID DATE HOURLY PLAN CHECK - YES 101-0000-42600 2.75 $192.50 $192.50 10/13/15 'PAID METHOD RECEIPT # %:'. -'� CHECK # CLTD BY OPUS BANK • CHECK R9966 1211000077 MFA <, DESCRIPTION . �` ACCOUNT .." QTY a '; AMOUNT PAID PAID DATE' HOURLY-PLAN CHECK - YES 101-0000-42600 1 $70.00 $70.00 10/13/15 PAID BY METHOD . RECEIPT # CHECK # CLTD` BY OPUS BANK CHECK R9966 1211000077 MFA Total Paid for BLDG CITY STAFF - PER HOUR: $835.00 $835.00 . 4. DESCRIPTION ACCOUNTQTY - ' AMOUNT PAID PAID DATE: BSAS SB1473 FEE 101-0000-20306 0 $9.00 $9.00 10/13/15 PAID BY METHOD ' ' RECEIPT # CHECK #' ; CLTD BY:. OPUS BANK CHECK R9966 1211000077 MFA Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $9.00 $9.00 DESCRIPTION ACCOUNT" QTY " AMOUNT "PAID _ PAID'DATE RESIDENTIAL, EA ADDITION 1,000SF 101-0000-42403 0 $49.32 $49.32 10/13%15 PAID BY x "; METHOD RECEIPT # =" CHECK # < CLTD BY OPUS BANK CHECK R9966 1211000077 MFA DESCRIPTION ACCOUNT QTY; & AMOUNTPAID PAID. DATE' RESIDENTIAL, EA ADDITION 1,000SF, PC 101-0000-42600 0 $20.32 $20.32 10/13/15 PAID BY METHOD RECEIPT #' " ".' CHECK #. CLTD. BY OPUS BANK CHECK R9966 1211000077 MFA -;'DESCRIPTION .: ACCOUNT QTY". AMOUNT'" PAID : PAID DATE RESIDENTIAL, FIRST 1,000SF 101-0000-42403 0 $145.03 $145.03 10/13/15 PAID BY METHOD _ _ - `RECEIPT # :' '_' CHECK # CLTD BY` OPUS BANK CHECK R9966 1211000077 MFA DESCRIPTION ACCOUNT" QTY` =AMOUNT PAID PAID DATE -RESIDENTIAL, FIRST 1,000SF, PC 101-0000-42600 0 $47.86 $47.86 10/13/15 PAID BY , �,, METHOD ` RECEIPT # CHECK # CLTD BY OPUS BANK CHECK R9966 1211000077 MFA Total Paid for ELECTRICAL - NEW CONSTRUCTION:. $262.53 $262.53 -.'DESCRIPTION,.' `' ACCOUNT ' , QTY - , AMOUNT ` PAID ....... . PAID DATE; CONDENSER/COMPRESSOR 101-0000-42402 0 $72.52 $72.52 10/13/15 PAID BY , METHOD RECEIPT # _ CHECK # CLTD BY OPUS BANK CHECK R9966 1211000077 MFA ;. DESCRIPTION ,'. ACCOUNT,,. �. QTY AMOUNT. PAID PAID GATE: CONDENSER/COMPRESSOR PC 101-0000-42600 0 $48.34 $48.34 10/13/15 t PAID BY n: METHOD, RECEIPT # CHECK #:.. -: CLTD BY 4 OPUS BANK CHECK R9966 1211000077 MFA DESCRIPTION ACCOUNT QTY ` .; AMOUNT:,,^PAID PAID DATE EXHAUST HOOD 101-0000-42402 0 $12.09 $12.09 10/13/15 . <PAIDBY e- METHOD -RECEIPT # a, CHECK # `'`' CLTD BY OPUS BANK CHECK R9966 1211000077 MFA 'DESCRIPTION = ,k ACCOUNT. QTY AMOUNT'a PAID PAID DATE'_ EXHAUST HOOD PC 101-0000-42600 0 $4.83 $4.83 10/13/15 PAID BY METHOD `RECEIPT #, CHECK W. CLTD BY " OPUS BANK CHECK R9966 1211000077 MFA DESCRIPTION' ACCOUNT' 'QTY AMOUNT' _ PAID r PAID DATE;' FURNACE 101-0000-42402 0 $108.78 $108.78 10/13/15 ` PAID BY• METHOD_ RECEIPT # CHECK # CLTD BY OPUS BANK CHECK R9966 1211000077 MFA DESCRIPTION ACCOUNT' ,QTY AMOUNT. PAID PAID DATE FURNACE PC 101-0000-42600 0 $72.51 $72.51 10/13/15 PAID BY ,: ;` METHOD ' '' 'RECEIPT # CHECK # CLTD BY OPUS BANK CHECK R9966 1211000077 MFA DESCRIPTION ACCOUNT QTY. .° AMOUNT: PAID tPAID DATE VENT FAN 101-0000-42402 0 $96.72' $96.72 10/13/15 N PAID.BY METHOD RECEIPT4, CHECK # CLTD BY OPUS BANK CHECK R9966 1211000077 MFA x DESCRIPTION ACCOUNT : f v m' QTY' ' '. AMOUNT.:' _ , PAID PAID: DATE VENT FAN PC 101-0000-42600 0 $38.64 $38.64 10/13/15 PAID BY METHOD RECEIPT #CHECK # CLTD BY' OPUS BANK CHECK' R9966 1211000077 MFA DESCRIPTION " ACCOUNT QTY AMOUNT PAID PAID DATE WALL HEATER 101-0000-42402 0 $49.42 $49.42 .10/13/15 PAIDAY METHOD RECEIPT # a CHECK # CLTD BY OPUS BANK CHECK R9966 1211000077 MFA DESCRIPTION ACCOUNT QTY AMOUNT, -- PAID PAID.bATE- WALL HEATER PC 101-0000-42600 0 $24.18 $24.18 10/13/15 PAID BY METHOD RECEIPT # CHECK #, CLTD BY