BSPN2017-0011!r
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: BSPN2017-0011
Property Address: 50630 BREVA
APN: 776330009
Application Description: GAS RELEASE ONLY
Property Zoning:
Application Valuation:
Applicant:
DONALD MACKENZIE
39083 ONE HOUSE WY
PALM DESERT, CA 92260
Twit 4 4 Qum&
DESIGN & DEVELOPMENT DEPARTMENT
BUILDING PERMIT
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
($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 Name
Lender's
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 4/3/2017
Owner: '
RMB CITRUS
18 PEPPERTREE
ALISO VIEJO, CA G
Contractor:
Lic. No.:
WORKER'S COMPENSA70N DECLARATION
I hereby affirm under penalty of perjury one o: 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 perfornance 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 Section =700 of the Labor Code, I shall forthwith
comply with those provisions.
Date:
Applicant:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMIMAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,OCD). IN ADDITION TO THE COST OF
COMPENSATION, DAMAGES AS PROVIDED FOt 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 theCity of La Quinta, its officers, agents, and
employees for any act or omission related to t ie 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
riot commenced within 180 days from date of issuance of such permit, or cessation of
work for 180 days will subject permit to cance'lation.
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 ordiiances 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: Signature (Applicant -or Agent):
Application Number: BSPN2017-0011
Property Address: 50630 BREVA
APN: 776330009
Application Description: GAS RELEASE ONLY .
Property Zoning:
Application Valuation:
Applicant:
DONALD MACKENZIE
39083 ONE HOUSE WY
PALM DESERT, CA 92260
Owner:
RMB CITRUS
18 PEPPERTREE
ALISO VIEJO, CA 0
Contractor:
Date: 4/3/2017
Llc. No.:
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Detail: GAS TEST INSPECTION FOR GAS SERVICE RELEASE ONLY - THIS PERMIT DOES NOT INCLUDE WORK
DESCRIPTION
ACCOUNT I CITY I AMOUNT
SPECIAL INSPECTION 101-0000-42404 0 $76.00
Total Paid for COMPLIANCE SURVEY/SPECIAL INSPECTION: $76.00