BELC2017-000278-495 CALLE TAMPICO .
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LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT
BUILDING PERMIT
Application Number: BELC2017-0002
Property Address: 78269 HACIENDA AVE
APN: 646280020
Application Description: SHUMA / PANEL CHANGE OUT 200AMP
Property Zoning:
Application Valuation: . $8,534.00
Applicant:
A R S AMERICAN RESIDENTIAL SERVICES OF C
965 RIDGE LAKE BLVD SUITE 201
MEMPHIS, TN 38120
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: C36, C10, C20 License No.: 765074
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
Lender's
VOICE (760) 777-7125
'FAX (760) 777-7011
INSPECTIONS (760 7-7153
Dat 1
Owner:
NANCY SHUMA
78269 HACIENDA
LA QUINTA, CA 92253
a CIZ
ti
Z
Contractor:
A R S AMERICAN RESIDENT! OFC
965 RIDGE LAKE BLVD SUIT
MEMPHIS, TN 38120
(951)276-9744
Llc. No.: 765074
WORKER'S COMPENSATMN 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 w for which this permit is issued.
I have and will maintain workers' compensation insurance, as required by
Secti 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: LIBERTY INSURANCE CORPORATION Policy Number: WC7631508631
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 3:00 of t Labor Code, I shall forthwith
comply with those provisions.
• / 3-/ 7 r
Date: 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 FORIN 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 appliotion 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 applice-tion 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 representatves of this city to enter upon the
above-mentioned property for inspection purposes.
Date: l Signature (Applicant ar Agent):
k
Date: 1/13/2017
Application Number:
BELC2017-0002
Owner:
Property Address:
78269 HACIENDA AVE
NANCY SHUMA
APN:
646280020
78269 HACIENDA
Application Description:
SHUMA / PANEL CHANGE OUT 200AMP
LA QUINTA, CA 9253
Property Zoning:
Application Valuation:
$8,534.00
Applicant:
Contractor:
A R S AMERICAN RESIDENTIAL SERVICES OF C
A R S AMERICAN R=SIDENTIAL SERVICES OF C
965 RIDGE LAKE BLVD SUITE
201
965 RIDGE LAKE BLVD SUITE 201
MEMPHIS, TN 38120
MEMPHIS, TN 3810
(951)276-9744
LIc. No.: 765074
Detail: ELECTRICAL PANEL - CHANGE OUT 200AMP FOR 200AMP. 2016 CALIFORNIA BUILDING CODES.
6
DESCRIPTION
...
• . , 11411
ACCOUNT QTY
AMOUNT
BSAS SB1473 FEE
101-0000-20306 0
$1.00
Total Paid for BUILDING STANDARDS ADMINISTRATION BSA:
$1.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
SERVICES
101-0000-42403
0
$25.33
DESCRIPTION
ACCOUNT
QTY
AMOUNT
SERVICES PC
101-0000-42600.
0
.$12.67
Total Paid for ELECTRICAL:
$38.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
PERMIT ISSUANCE
101-0000-42404
0
$96.27-
96.27Total
TotalPaid for PERMIT ISSUANCE:
TCITALS:
$96.27
$135.27
1
Bin #
Permit #f
Project Address:7��
..City of La Quin to
Buifding &r Safety Division
78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-701,2
...Building Permit Application and Tracking Sheet
Owner's Name: C
A. P. Number:
t
Address:
Legal Description:
City, ST, Zip:�� "---X3
Contractor:
Tele ho
n Jls7
Address:
Project Description:
QS7
City, ST, Zip: /c--�/o$ ��/ �`�'S"Y 3
TeleP h0 n C-&O416 7.S
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State Lie. #
City Lie. #--0165
Arch.,'Engr.; Designer:
Address:
City, ST, Zip:
Telephone:
Construction Type: Occupancy:
State Lie. #:
r
Project eet tYPa circle one): New A dd'n Alter Repair-ai
Demo.
Name of Contact Person:
Sq. Ft.: C a
# Stories:
# Units:
Telephone # of Contact Person:
Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
t!
Submittal
Req'd
Rcc'd
TRACIGNG
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Cafes.
Reviewed, ready for corrections
Plan Check Depssit
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 corrcctions/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
Review, ready for corrections/issue
Developer Impazt Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date or permit issue
School Fees.
Total Pcrntit Fccs