HomeMy WebLinkAboutHVRC19-0294APN/Tract/Lot No: Owner: Contractor: Applicant:
637470020 DONALD L WARNER SABRWA SERVICES INC SABRINA SERVICES INC
TR 31836 43310 ARIZONA ST 72216 NORTHSHORE ST #101 72216 NORTHSHORE ST #101
20 PALM DESERT, CA 92211 THOUSAND PALMS, CA 92276 THOUSAND PALMS, CA 92276
p60)343-2121 p60)343-2121
Licensetl Contrector Declaration Fee Summary
I hereby af(i�m untle� oenaltv ot oenury Iha� I am licensetl untle� pmNsions ot Chap�e� 9 qRCHNE FEE - BSX11 UP TO 11X11 GL-11p00003411600 3�A2
��'� (commencing with Section ]Q�0) o( Oihsion 3 of �he Business antl Pro(esslons Gotle,
— antl my Ilcense Is m full force and eKeci. GREEN B�DG FEE SB14]3 GL-61�0 000-2 2 81000 S1 DO
Initial
RESIDENTIAL HVAC CHANGE Ol1T GL11000003221100 5159.00
pwner-euiltler Oeclaration Total Fees Paid: 5160.42
�I M1ereby affirm ontler oenaltv of oenory ihat I am exempt irom Me Contrectors' Stale � herebya/iirtn untler the penaltyofperjuryfhaf fhere is a consfruc[ion lentling aqencylor Ne
License Law for IM1e reason(s) Intlicatetl below by Ne checkmaB(s) I have placetl neM Perlormance o(fhe woik Ior which fhis permd is lssuetl (Sec J09], Clvil Cotle)
ro Yhe applicable i�em(s) Section ]031.5 Business and Pmfessions Coae: Any city or �entlers Name antl atltl�ess
wunry whlch requires e permll to constmct, alter, improve, tlemolisq or repalr any
simcWre, prior to issuance, also requires Ihe applican� for Yhe permit to (Ja a signe0 Asbestos Decla�ation
stalement ihat he or she is lioonsotl pursuant to tha pmvlslons of Ihe ConVectors' Stata
LicenseLew(Chaptor9�cammemm�gwrthSection]�007of�insion3ofiM1aBusiness WfiltenasbestosnotificalionpursuanlloP�ofTitle40oflheCodeo(FaderalRegulationslsrequired
and Pmfessians Code) or �ha� M1e or she Is exemp� antl �he basis for �he allegetl when asbestos edsts in buildings, or portions t�etE�f untlergoing demolition. I hereby tleclare �hat
exemption. Any mola�ion ol5ectlon ]0315 bY any appllcant for a permll sublects the tlemolltion authorizetl by ihis permli I fr o tmcli �ha� tloes or does nol conlain
applican� to e ciNl penelty of not more than fiva M1untlretl tlollare (35�0J.) asbestos, or thet _ no tlemoli�f I�r2ed by Is permll.
� I, as owner of tM1e property. or my employees with wages as their sole compensation, NOTICE Vou may pmtest any f e le s for ihi e t in accordance with CA Gov Cotle Sec. fifi020
will tlo tM1e �wrk, antl the sWcture is not intended or oRetea (or sale (Sec. ]044, (a). The pm�es� mus� salisfy �he r q ement�( ov. Code Sec.66020(a) and musl be tiletl mithin 90
Business and Pmfessions Cotle. The ConUaclors Slate Lmense �aw tloes not apply �o tlays of �he date of Ihis nolice. In tlilion, y0u must lender payment ot Ne protestetl fees a� �he lime of
an owner of propedy viho builtls or Impmves Ihe property, pmv�detl that Ne �pe payment or prodd tlence o arrenge ents lo pay Ihe pmles�etl fees or exactions at Ihe time they
Improvemen�s are not Inlended or offere0 br sala. If, M1owever, iM1e butltlinq or ere tlue If Ihey ere not alr Oy tlae_
impmvemantlssoldwilM1inoneyearolcompletion,�he0wner-BulltlerwillheveNe \�
burtlan of pmHnq ihat It was not built or Impmveo for Ihe purpose of sele.) y
� I, as owner of �he pmperty, am excluslvely conUacting with Imensetl conhactors to � y
cons�mcl ihe pro�ect (Sec. I044, Business antl Professions Gotle�. The ConUacmfs i '
Llcense Law tloes nol apply to an owoer of pmpetly who builds or impmvas thareoq �
aotl who con�2qs for such pro�ec�s wLLh e Ilcensea conUaclor porsuant to iM1a �
ri011V2C1016' $�2�8 LICBIISE LdIY )
� I am exempt fmm Licansum untlerthe ConVectors' Stele License Law r tlie
tollawing reeson�
�
Date/SlgnaWre oi propetly owner or agent /
Workers' Comoensation Declaration
WARNING: FNIWRE Ta SECl1qE WaRRERS' COfdPENSATION COVERNGE IS ONLFWFUL ANO SHALL
SUBJ W T NN EMP�OTEF TO CRIMINAL PENfiLTIES ANO CML FlNES UP TO aNE MON�RE� TMOOSf�N�
OOLLqRS �510D,0�0�, IN P��RION TO THE COST OF <OMPENSATION �AMAGES AS PftON�EO FOR IN
SECTION J]�6 aF THE LABOP CODE, IMEREST, ANO HTTORNET'S FEES.
1 M1erebv aKrm untlm Ihe ocnaltv of ver'ury ONE of the followina tlwlara['ons
I have end will malnteln a cetlificete of consenl to selLinsure forwoMers'
compensation, issuetl by the Oiredor of Intlusirial Relatmns as pmNtletl for by Section
Initial 3]00 of �he Labor Code, for ih� pertoimance o( Ne woM for which t�is permit issued
Pollcy No.
I have antl will mamtaln woAers compensaiion insurence, as required by Section
3I00 oi Ne �abor Cotle, for �he pertormance of Ihe work forwhich �his permlt is
Issued. My workers' campensation Insurance carner and poM1cy number are
Initial CarnerBPOIIcyNumberNOVACASUALTVCOMPANV515WK1 00 00001 0 0
EKoiralmn Oate 6I28I2019
I cotlify �ha� in Ihe peRormence of �hewoB �or wM1mh Ihis permit Is issueq I shall not
employ any person In any manner so as to become su��ect to the workers'
compensalion laws ot Callfomia antl agree �hat if I s�ould become subject �o Ihe
��:V� workers compensation pmmsmns of Secfion 3"!00 of Ihe Labor Code, I s0all fo�hwi��
com ply �wim �m7os�e p�m'�Hsions //+/ �
Initial pa�a�Appiiwnt �W '
Project Address: 43310 ARIZONA ST Project Description: STON, FURNACE, EVAP COIL
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Project Address:
City of Palm Desert
Department of Building and Safety
Buildinq Permit Application
31n A-r�zd�0.
(For ONce Use OnlyJ
JOB ID: C1 V�� � I-�� a� �(
PLANS FILED:
Total Value of work: $ 7 Z�� Note: Plan Review Fees may 6e adjusted afrerPlan Review
Project Description (be specific):
s%� /y Seer iL��d �����.� �vta-P d- ro..de.�sers :�c%�ec�
vm brn
ContraIetor Business Name Property Owner Name /
Coaa v�E � 1 0. Vp,� ..R« i9 in �Q /�d �t%G:!✓! C/-`
Adtlress�C- Z�6 O(,�.41.5 NVre �7T �F �'O) Address� ��v ,C%r, z.o�,a ST
�•
o�ri�--bdv c�� �a �.-,,. Z�P 2 Z 7 6 o�tY �ul o,-, Dese�-� Z'P 9 2 L�/
Phone /760 �� 3� Z Z � Phone "o � 3 Z�
�
Fax Fax
E-mail E-mail
Contrector License No.
❑Architect Name ❑Designer Name Engineer Name
Address Address
City Zip City Zip
Phone Phone
Fax Fax
E-mail E-mail
License No. License Na.
Signature
.---�
'�, U' I � ,� .:� t „� ��e=,
Contact Telephone Number
��'Go� 3Y3 2f ZI
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� �c>.C22ant
PLEASE COMPLETE THE REVERSE SIDE
Date
`'-ZZ�/`!
73-510 Fred Waring Drive, Palm Desert, CA 92260 •(760) 776-6420 •(760) 776-6392 fax • www.cityofpalmdesert.org
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