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HomeMy WebLinkAboutHVRC18-0350J City of Palm Desert "+~^` Building Safety Department PERMIT NUMBER: ISSUE DATE: and - 73510 Fred Waring Drive HVRC18-0350 6/5/2018 Palm Desert, CA 92260 y Permit Type: HVAC CHANGE OUT RESIDENTIAL Appl. Date: 6/5/2018 Permit TIER 1-LESS 15 SEER Subtype: Job Valuation: $9,002.00 Appr. Date: 615/201 B Exp. Date: 121212018 Project Address: 42748 ADALIN WAY Project Description: APN1Tract/Lot No: Owner: Contractor: Applicant: 634181063 BRIGITTE L DAVIS A R S AMERICAN RESIDENTIAL A R S AMERICAN RESIDENTIAL INT COM LOT 10 11 P 42748 ADALIN WAY SERVICES OF CALIFORNIA INC SERVICES OF CALIFORNIA INC 13P MB 227161 TR 23322 PALM DESERT, CA 92211 965 RIDGE LAKE BLVD. #201 965 RIDGE LAKE BLVD, #201 -5 MEMPHIS, TN 38120 MEMPHIS, TN 38120 56 (951)276-9744 (951)276-9744 Licensed Contractor Declaration Fee Summary I hereby affirm under penalty, of pedury that I am licensed under provisions of Chapter 9 ARCHIVE FEE - 8.5X11 UP TO 11X17 GL-1100000-3411600 $0,42 (commencing with Section 7000) of Divislon 3 of the Business and Professions Code, and my license is in full farce and effect. GREEN BLDG FEE SB1473 GL-6100000-228100D $1.00 Initial RESIDENTIAL HVAC CHANGE OUT GL-11D0000-322110U $1%00 Total Fees Paid: $160.42 Owner -Builder Declaration 1 hereby affirm under Penalty of oedury that I am exempt from the Contractors' State I herebyartirm under the penalty of perjury that there Is a construction lending agencyfor the License Law for the reason(s) indicated below by the checkmark(s) I have placed next performance offhe work for which this permit is issued (Sec 3097, Civil Code) to the applicable item(s) Section 7031.5 Business and Professions Code: Any city or Lenders Name and address county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to issuance, also requires the applicant for the permit to file a signed Asbestos Declaration statement that he or she is licensed pursuant to the provisions of the Contractors' Slate License Law(Chapter 9(commencing with Section 7000) of Division 3 of the Business Written asbestos notiticatlon pursuant to Part 61 of Title 40 of the Code of Federal Regulations is required and Professions Code) or that he or she is exempt and the basis for the alleged when asbestos exists in buildings, or portions thereof, undergoing demolition. I hereby declare that exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the demolition authorized by this permit is from construction that does or does not contain applicant to a civil penalty of not more than five hundred dollars ($500).) asbestos, or that no demolition is authorized by this permit. 1, as owner of the property, or my employees with wages as their sole compensation, NOTICE: You may protest any of the fees for lh€s permit in accordance with CA Gov Cade Sec. 66020 will do the work, and the structure is not intended or offered for sale (Sec. 7044, 'The (a). The protest must satisfy the requirements of Gov. Cade Sec.6602D(a) and must be filed withtm 90 Business and Professions Code: Contractors' Stale License Law does not apply to days of the dale of this notice. In addition, you must tender payment of the protested fees at the time of an owner of property who builds or improves the property, provided that the improvements are not intended or offered for sale. If, however, the building or the payment or provide evidence of arrangements to pay the protested fees or exactions at the time they improvement is sold within one year of completion, the Owner-BUilder will have the are due if they are not already due. burden of proving that it was not built or improved for the purpose of sale.) I, as owner of the properly, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a licensed contractor pursuant to the ' Contractors' State License Law.) I am exempt from Llcensure under the Contractors' State License Law for the following reason: DatelSignalure of property owner or agent Workers' Compensation Declaration 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 ATTORNEYS FEES. I hereby affirm under the Penalty of Perjury ONE of the fotiovvina declarations: I have and will maintain a certificate of consent to selfAnsure for workers' compensation, issued by the Director of Industrial Relations as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit issued. Initial Policy No. 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: Initial Carrier& Policy Number Expiration Dale I certify that in the performance of the work for which this permi ' sued, i shall not employ any person in any manner so as to became subject work compensation laws of California and agree if I shout a me ject 1 he workers' compensation provisions of Se 700 o D 1 fo ith comply with those provisions. Date Initial Applicam 4 City of Palm Desert Department of Building and Safety Building Permit Application Project Address: 42.1 Total Value of work: $ /' 0 d Z Project Description (be specific): ter, (For Office Use Only) JOB ID: �V W b_~50 PLANS FILED: ite # Note. Plan Review Fees maybe adjusted after Plan Review Contractor us' ess Name Property Owner Name { ,Q_ Address - Address CXC City � Zip City Zip Z. Phone 6�LQLQ C) CM0,777 �] Phone IU Fax Fax E-mail E-mail Contractor License No. Z ❑Architect Name []Designer Name Engineer Name Address Address City Zip City Zip Phone Phone Fax Fax E-mail E-mail License No. License No. Applicant Name Signat Date C6�vo' wz ,7,,,,,,e vs,$ intact Telephone Number )zcw-3/39 E-bra l vv_.. PLEASE COMPLETE THE REVERSE SIDE 73-510 Fred Waring Drive, Palm Desert, CA 92260 • (760) 776-6420 - (760) 776-6392 fax • www.cityofpalmdesert.org v+ z z � CD ao 4 C m m a 0 3 � O C r _ r � � a r mC) o cn F, 00 O Ln a 0 C CD rD m rD a N 2 P m r Ln OD O rn � o Vl CL fD a n ur = w m in m O VV) n m x m L O 0 o� x ram*, 3 Oti v C n V! M M w m a O 0 T m m rr m n 0 3 w 0 lu H G rr Q. 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