BMCH2017-003778-495 CALLE TAMPICO C& 0 V -` Quiott VOICE (760) 777-7125
LA QUINTA, CALIFORNIA 92253FAX (760) 777-7011
DESIG ` EVELOPMENT DEPARTMENT FAX
(760) 777-7153
ILDI RMIT
'U ® Date: 4/28/2017
Application Number: BMCH2O17-0037 OAK
er:
Property Address: 79050 HIGHWAY 111 APR 2 g 2017.ND AMERICAN LAQUINTA PAV
APN: 600390029 BOX 9271
Application Description: SPROUTS MARKET / CHANGE OUT (5) HVAC SL'5j BROOK, IL 92253
Property Zoning: DESIGN S LAQUINTA
Application Valuation: $13,000.00 pY&�ECOPMENTDEPARTMENT
Applicant: Contractor:
• r
GREGORY PANEK K I C REFRIGERATION MECHANICAL & CONTROL
914 E KATELLA AVENUE 27890 CLINTON KEITH ROAD SUITE
ANAHEIM, CA 92805 D-415
MURRIETA, CA 92562
(855)542-2653
Lic. No.: 990241
LICENSED CONTRACTOR'S DECLARATION.
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Business and Professions Code,
and my License is in full force and effect.
License Class: C38, C-7. C20, CSO License No.: 990241
DRate yZ$ ^ 7 Lontractp� --_
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.).
(__j 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:
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:
Carrier: HARTFORD INSURANCE COMPANY OF THE MIDWEST Policy Number:
57 W ECZU6271
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 3700 of the Labor Code, I shall forthwith
comply with those provisions.,
lf-2.9—/ i Ap �--
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 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 cancelation.
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. ,
�O �% . J
Date: Signature-(Applicant-CantA
Date: 4/28/2017
Application Number:
BMCH2O17-0037
Owner:
Property Address:
79050 HIGHWAY 111
INLAND AMERICAN LAQUINTA PAV
APN:
600390029
P 0 BOX 9271
Application Description:
SPROUTS MARKET / CHANGE OUT (5) HVAC SYSTEMS
OAK BROOK, IL 92253
Property Zoning:
Application Valuation:
$13,000.00
Applicant: Contractor:
GREGORY PANEK K I C REFRIGERATION MECHANICAL & CONTROL
914 E KATELLA AVENUE 27890 CLINTON KEITH ROAD SUITE
ANAHEIM, CA 92805 D-415
MURRIETA, CA 92562
(855)542-2653
LIc. No.: 990241
------------------------------------------------------------------ -------------------------
Detail: CHANGE OUT 5 ROOF MOUNTED UNITS PER 2016 CMC CODES
9
e
FINANCIAL INFORMATION
DESCRIPTION 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
HVAC CHANGEOUT - PACKAGED UNIT
101-0000-42402
0
$190.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
HVAC CHANGEOUT - PACKAGED UNIT PC
101-0000-42600
0
$126.65
Total Paid for CHANG =OUT: $316.65
DESCRIPTION
ACCOUNT
QTY
AMOUNT
Credit Card Fee
101-0000-43505
0
$7.54
Total Paid for Credit Car -3 Feer $7.54
DESCRIPTION
ACCOUNT
QTY
AMOUNT
PERMIT ISSUANCE
101-0000-42404
0
$96.27
Total Paid for PERMIT ISSUANCE: $96.27
DESCRIPTION
ACCOUNT
QTY
AMOUNT
TECHNOLOGY ENHANCEMENT FEE
502-0000-43611
0
$5.00
Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00
,,
Bin. #
Permtt # aNA / n�
City, 'f La Quanta
Building 8r Safety Division
P.O. Box 1504,78-495 Calle Tampico
La.Quinta, CA 92253 -:(760) 777-7012
Building Permit' Application and Tracking Sheet
Project Address: SQ CA
iAWll, I LRCulmTA q2J51
Owner's Name:.S ,-eki.+S 1'A�Y�CYd IvlG�r�}
A. P. Number.
Address: o SO CAVtWy I l l
Legal Description:
City, ST, Zip: Uir\ }q CA C{ ZL$3
Contractor. r
(� (Avl�vu�5
Telephone:(." ;�:°
Address: 2-+ih
q A SUi4eD
Project Description: C (5
City, ST, Zip: M �.a C A
�I 2,56 L
i S n x i S '� n' ►' o o
Telephone S 544 _ 53
l
State Lic. # : 01q0'24-1
Arch., Engr., Designer. Care
City Lia 0,
ek
Address: \
rn �-j
City., ST, Zip: e-
q 2 05'
Telephone: L'+k-I) 3 9,S ' 1 35
State Lic. #: k ¢�
Name of Contact Person:C
;w " »
1' e
Construction Type: V Occupancy:
Project type (circle one): New Add'n Alter epa Demo
Sq. Ft -:2 s
# Stories: 2 # Univ: s
Telephone # of Contact Person:
s - 3 5
Estimated Value of Project: 0 4
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Reed
TRACIMG
PERMTPFEES
Plan Sets
Pian Cheek submitted
Item Amount
Structural Calan.
Reviewed, ready for corrections
Plan Check Deposit. .
Truss Calcs.
Called Contact Person
Plan Check Balance •
Title 24 Calci.
Plans picked up
Construction
Flood plain plan
Plans resubmitted..
Mechanical .
Grading plan
2'! Review, ready for correctionstissue
Electrical
Subeontaetor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
SALL
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
'^' Review; ready for correcdonsAssue
Developer Impact Fee
Planning Approval
Called Contact Person
A.LP.P.
Pub. Wks. Appr '
Date of permit Issue
School Fees
Total Permit Fees