11-1311 (TT)P.O. BOX 1504
78-495,CALLE TAMPICO
LA QUiNTA, CALIFORNIA 92253
Application Number:
1110- low
-00001311
Property Address:46@152903
ROSS AVE
APN:
767-670-0187 -330761-.
Application description:
TEMPORARY TRAILER
Property Zoning:
LOW DENSITY RESIDENTIAL
Application valuation:
1200
Applicant:
c&` °F4Q"-
Architect or Engineer:
.�JA .
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I m licensed under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business d Pr essionals Code, and my License is in full force and effect.
License Class: B 1 A. A License No.: 671203
ate: 1-3 -12- C tractor:
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)•:
1 _) 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 burdenofproving 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: - Q
Lender's Address: _01r
LQPERMIT
Owner:.
LOTHENBACH ROBERT J.
1000 VALLEY PARK DR
SHAKOPEE, MN 55379
Contractor:
PIERCE CORPORATION, ANDREW
P.O. BOX 3420
PALM DESERT, CA 92261-3420
(760)346-3228
Lic. No.: 671203
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 12/13/11
AJAN 03 2011
C W OIF to aulmta�
FINANCE DEPT.
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.
IL 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 STATE FUND - Policy Number 0000745-2010
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 de, II, f hwith comply with those provisions.
Kate: -�Z pplicant:�
WARNING: FA LURE 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 Director of Building and Safety 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 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 y nstruction, and hereby authorize representatives
of ttl county to enter uuppoonn,tha above-mentioned property f ( ct rposes.
af5 te: I' 3 ' 12 gnl ature (Applicant or Agent):
Application Number" . . . . . 11-00001311
Permit . .
. TEMP TRAILER
/ MOBILE HOME
Additional desc
Permit Fee . .
. 200.00
Plan Check
Fee
.00 .
Issue Date
Valuation
1200
Expiration Date..
6/10/12
Qty Unit Charge Per
Extension
BASE
FEE
200.00
Special .Notes and
Comments
TEMP CONSTRUCTION
TRAILER PER MUP
#
2011-1036.
Fee summary
Charged
Paid Credited
Due
Permit Fee Total
200.00,
00
.00
200.00
Plan Check Total
.00.
.00
.00
.00
Grand Total
200.00
.00
.00
200.00
LQPERMIT
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NOLS]]fa >s Updated footprint to follow- +
mrd DATE ISSUED: 11.16-11
REVISIONS:
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mrd DATE ISSUED: 11.16-11
REVISIONS:
Bin #.
Cityof La n�.%i�it,A
�C
Building 8t- Safety Division
P.O. Box 1504, 78-495 Cafie Tampico . .
La Qu►nta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit # . ;\ .
�\ `3
l
Project Address: f!Z • D?, R Os S A V IL,
Owner's Name:
A. P. Number: �! t ' 0 0/25
Address:
Legal Description:
City, ST, Zip:
Contractor: (> (e4eGF
w arc.:>:
Telephone:
Address: q 1. f —g53:5- or w_,p e yA j
Project Description:
City, ST, Zip: b4z,/t1 r CA . 122,6
j r% / X L w/u6 r&+t-4,W;0V . 7ILA'J4400e-
Tele hone:
p -Awl -3(0-.;7-2,9
}J.i)jC�k,µ�}':RJi•�^. i$}'F•. •>. :vii". .yV} �.
State Lic. # : GN
City Lia #.-
Arch., Engr., Designer:
Address:
City., ST, Zip:
Telephone:dh:l f ,
s.
State Lic.#:<'.�...
I
Name of Contact Person: /V A-rit „
r.
Construction Type: 5 Occupancy:
..
Project type (circle o _ e Add'n Alter Repair Demo
Sq. Ft.:
#Stories:
#Units:
Telephone # of Contact Person:1.
2';j"^,' a
Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS UNE
N
Submittal
Req'd
Recd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Tithe 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
A.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:
''' Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
#
City of La Quanta
Building 8t Safety Division
Box 1504,78-495 Calle Tampico
[a.Qdnta, CA 92253 -:(760)'777-7012
Building Permit -Application' and Tracking Sheet :
-Permit #P.O.
i�
Project Address: ?j Oma►
owner's Name:.
A. P. Number.
Address: .
Legal Description:
Contractor..A� O f ` ''s
City, ST, Zip:
" -� �"
Telephone: �,. , , ,
.
Address:
Project Description: \jj(t**.- ( f.
City, ST, Zip:"
Telephone' 60
r
City Lir. #;
State Lic. #: Trl
Arch., Engr., Designer
Address:
City., ST, Zip:
Telephone: Construction Type Occupancy:
State Lic. #: Project type (circle one): New Add'n Alter Repair Demo
Name of Contact Person: Sq. Ft.:#Stories: # Units:
Telephone # of Contact Person1bo Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS UNE
N
Submittal
Req'd
Recd
TRACKNG
PERMIT FEES
Plan Sets
Plan Check submitted
Item Amount
Structural Calcs
'i
Reviewed, ready for corrections
Plan Check Deposit. '
Truss Calcs.
Called Contact Person
Plan Check Balance.
Title 24 Cates.
Plans picked up
5 /5
Construction
Flood plain plan
Plans resubmitted
Mecharilcsl
Grading plan
2`' Review, ready for corrections ue
Electrical
Subcontactor List
Called Contact Person
(
Plumbing
Great Deed
Plans picked up
S.M.L
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
7rd Review, ready for correctlonsfissne
Developer Impact Fee
Planning Approval.
Called Contact Person
A.LP.P.
Pub. Wks. Appr
Date of permit issue
School Fees
7-1 Total Permit Fees
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