HomeMy WebLinkAboutHVRC18-0342City of Palm Desert
PERMIT NUMBER:
ISSUE DATE:
Building and Safety Department
735Fred Waring Drive
HVRC18-0342
611/2018
Palm Desert, CA 92260
Permit Type: HVAC CHANGE OUT
Appl. Date! 6/1/2018
_
RESIDENTIAL
Permit TIER 1-LESS 15 SEER
Appr. Date: 6/1/2018
Subtype:
Exp. Date: 1112812018
Job Valuation: $4,435.00
Project Address: 295 AVENIDA DEL. SOL
Project Description:
APN1TractlLot No:
Owner:
Contractor:
Applicant:
622066003
LYNNE ELIZABETH VELLING
ANTHEM MECHANICAL
ANTHEM MECHANICAL
INT IN COMMON TR
295 AVENIDA DEL SOL
53800 POLK STREET
53800 POLK STREET
11454 MB 97162 & PM
PALM DESERT, CA 92260
COACHELLA, CA 92236
COACHELLA, CA 92236
74143
(760)895-2621
(760)895-2621
3
Licensed ContractorDeclAraa ion
Fee Summary
I hereby affirm under penalty of eedury that I am licensed under provisions of Chapter g
ARCHIVE FEE, a.5X11 UP TO 11X17 GL-1100000-3411600 $0.28
(commencing with Section 7000) of Division 3 of the Business and Professions Code,
and my license is in full farce and effect.
GREEN BLDG FEE SB1473 GL-61000DO-2281000 $1-Do
nl I
RESIDENTIAL HVAC CHANGE OUT GL-110DOD0-3221100 $159.00
Total Fees Paid: $160.28
Owner -Builder Declaration
l hereby affirm under the penalty of perjury that there is a construction lending agency for the
1 hereby affirm under enal of pe6ury that I am exempt from the Contractors' State
License Law for the reason(s) indicated below by the checkmark(s) I have pieced next
performance of the work for which this permit is issued {Sec 3097, Civr7 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
Asbestos Declaration
structure, prior to 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 Contractors' Slate
License Law(Chapter 9(commencing with Section 7000) of Division 3 of the Business
Written asbestos notification 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.
i, as owner of the property, or my employees with wages as their sale compensation,
NOTICE: You may protest any of the fees for this permit in accordance with CA Gov Code Sec. 66020
will do the work, and the structure is not intended or offered for sale (Sec. 7044,
(a). The protest must satisfy the requirements of Gov. Code Sec.66020(a) and must be filed within 90
Business and Professions Code: The Contractors' State License Law does not apply to
days of the date of this notice. In addition, you must tender payment of the protested fees at the time of
an owner of properly who builds or improves the property, provided that the
the payment or provide evidence of arrangements to pay the protested fees or exactions at the time they
improvements are not intended Or offered for sale. If, however, the building or
are due if they are not already due.
improvement is sold within one year of completion, the Owner-Buitderwill have the
burden of proving that it was not built or improved for the purpose of sale.)
1, as owner of the property, am exclusIvely contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code: The Contractor's
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 Licensure under the Contractors' State License Law for the
following reason:
DatelSlgnature of property owner or agent
Workers' Corn pensation Declaration
WARNING; FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND
DOLLARS 15100,eea], IN RDDR[ON TO THE COST OF COMPENSATION DAMAGES AS PROVIDED FOR IN
SECTION 37a6 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
I hereby affirm under the penalty of perlury ONE of the following declarations:
I have and will maintain a certificate of consent to self -insure 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.
Inl I
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
-I laE
issued. My workers' compensation insurance carrier and policy number are:
Carrier & Policy Number
Expiration Date
1 certify that in the performance of the work for which INS permit Is Issued, I shall not
orkers'
employ any person in any manner so as to become s/V-�
compensation laws of California and agree that if I shbeo the
workers'compensation provisions of Section 3700 ofll forthwith
complywiththose ""ons.
I i I
Date Applicant
City of Palm Desert:
Department of Building and Safety
Building Permit Application
(For Office Use Only)
JOB ID: CwP-Cts-03gc�-
PLANS BLED:
Project Address: 9 Suite #
Total Value of work: $ Q Mote: Plan Review Fees may be adjusted after Plan Review
Project Description (be specific): 191D/1 11�1 12i3OA
Contractor Business Nam
Property Owner Manya
Address r
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Address
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Phone
Fax
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Contract License No.
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CiArchitect Name
❑Designer Name
Engineer Name
Address
Address
city
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City
Zip
Phone
Phone
Fax
Fax
E-mail
E-mail
License No.
incense No.
Applicant Name
Signature
Date
Cl f� Y\ G
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Contact Telephone Number
E-Mat
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PLEASE COMPLETE THE REVERSE SIDE
73-510 Fred Waring Drivel Palm Desert, CA 92260 • (760) 776-6420 • (760) 776-6392 fax • www.cityofpalmdesert.org
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