BSPN2015-004978-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
4 � �ui�c1cv
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING PERMIT
Application Number: BSPN2015-0049
Property Address: 79775 HIGHWAY 111103
APN: 600440005
Application Description: HALO 8 SPECIAL INSPECTION
Property Zoning:
Application Valuation:
Applicant:
JAMIE RICE
79775 HIGHWAY 111 STE 103
LA QUINTA, CA 92253 \
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 Address:
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Contractor:
LIc. No.:
9/28/2015
WORKER'S COMPENSATIION DECLARATION
I hereby affirm under penalty of perjury one ofthe following declarations:
I have and will maintain a certificate of consent to self -insure for workers'
compensation, as. provided for by Section 3700Lof the Labor Code, for the performance
of the work for which this permit is issued.
I have and will maintain workers' co.'npensation 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 polity number are:
Carrier: _ Policy Number:
I certify that in the performance of tie 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 tha-, if I should become subject to the
workers' compensation provisions of Section 3:00 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 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 isuance of such permit, or cessation of
work for 180 days will subject permit to cancellc tion.
I certify that I have read this application and sta-e 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 representataes of this city to en u on the
above -me do ed prop, yy f pection purpcses.
Date f� ature,(Applicant,c . a 5s
n'
FINANCIAL INFORMATION
i3 is DESCRIPTION4
Y- ACCOUNTUN ryAMOUNT}`
17 t -ti PAID • ' "F
D
PAID AT, E"
SPECIAL INSPECTION
101-0000-42404 0
$72.52 $72.52
9/28/15
PAID BY ;` - a
%+'r't,n`METHOD .v4v,, $ "�[RECEIP_T # y HEC #d
c�CLTD BY
JAMIE RICE
CHECK R9526 0000
MFA
Total Paid for COMPLIANCE SURVEY/SPECIAL INSPECTION:. $72.52 $72.52
TOTALS:
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Bin #City
of La Qulnta
Buifding 8t Safety Division
78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking ShEet
Permit #i
�Prcjcct Address: �% �,• l l
Owner's Name:
A. P. Number:
Address:
Legal Description:
City, ST, Zip:
ntra r:
Co ct 0
Telephone:
Address:
ProjecA Description:
City, ST, Zip:
i a U�
ne•
TeleP ho .
State Lie. # :
City Lie. #.-
:Arch.,
Arch.,Engr., Designer:
Address:
City, ST, Zip:
Telephone:
Construction Type: Occupancy:
:
State Lie. #•
t
Project tYPa circle one): New Add'n Alter Repair Demo
Name of Contact Person:
Sq. Ft.:
# Stories:
# Units:
Telephone # of Contact Pe n: — ig(
$stimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
#/
Submittal
Req'd
Rec'd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Cales.
Called Contact Person
Plan Check Bala -ice
Title 24 Calcs.
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.
JI.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:=
7rd Review, ready for eorrectionstissue
Developer Impart Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees,
Total Permit Fecs
Description: HALO 8 SPECIAL INSPECTION
Type: SPECIAL INSPECTION
Subtype:
Status: ISSUED
Applied: 9/28/2015 MFA
Approved: 9/28/2015 MFA
Parcel No: 600440005 Site Address: 79775 HIGHWAY 111 103 LA QUINTA,CA 92253
Subdivision: PM 036269
Block:
Lot: 5
Issued: 9/28/2015 MFA
Lot Sq Ft: 0
Building Sq Ft: 0
Zoning:
Finaled:
Valuation: $0.00
Occupancy Type:
Construction Type:
Expired: 3/26/2016 MFA
No. Buildings: 0
No. Stories: 0
No. Unites: 0
-
Details:
STE 103
Printed: Monday, September 28, 2015 1:00:46 PM 1 of 2
SYSTEMS
CONTACTS
_
_ NAME.TYPE
_..
tNAME r
o
- - ADDRESS1
CITY
STATE ZIP
PHONE
FAX
EMAIL = :"
APPLICANT
JAMIE RICE
79775 HIGHWAY 111
LA QUINTA
CA 92253
-
STE 103
OWNER
P6K PORTFOLIO KDP
2301 ROSECRANS STE
EL SEGUNDO
CA 92253
2110
Printed: Monday, September 28, 2015 1:00:46 PM 1 of 2
SYSTEMS
INSPECTIONS
SEQID INSPECTION TYPE :� INSPECTOR° �� 'SCHEDULED 'COMPLETED ' 'RESULT •�_ REMARKS'=�_ NOTES
DATE DATE"
SPECIAL INSPECTION JFU 9/28/2015
BOND INFORMATION
""` AlIACHIVIEIVIS
Printed:. Monday, September 28, 2015 1:00:46 PM 2 of 2
SYS'lF.MS