RC-14-36878-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
CApplication Number:
RC -14-368_
Property Address:
45280 SEELEY DR
APN:
604630053
Application Description:
INFUSION CENTER T.I.
Property Zoning:
Application Valuation:
$214,000.00
Applicant:
EISENHOWER MEDICAL CENTER
39000 BOB HOPE DR
RANCHO MIRAGE, CA 92253
4
Twit 4 VOICE (760) 777-7125
FAX (760) 777-7011
COMMUNITY DEVELOPMENT DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: 7/11/2014
Owner:
EISENHOWER MEDICAL CENTER
39000 BOB HOPE DR
RANCHO MIRAGE, 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: B License No.: 343108
te: �"ontractor:
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
permit subjects the applicant to a civil penalty of not more than five hundred dollars
($500).:
(1 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 ) 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:
V
Contractor:
GREEN TOWNE INC
P 0 BOX 13981
PALM DESERT, CA 92255
(760)636-5701
Llc. No.: 343108
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.
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: _ Policy Number: _
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 Code, I shall forthwith
comply with those provisions.
k `` icantt////..
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 15 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 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
construction, and hereby authorize representatives of this city to enter upon the above-
mentioned property for inspection purposes.
Qate:� 1)( � \ SIgAatdr<Applicant or Agent):
FINANCIAL INFORMATION
-=DESCRIPTION.
`~ ACCOUNT"
°QTY,
AINI,OUNT ,
PAID
PAID DATE
ART IN PUBLIC PLACES - COMMERCIAL.
REMOD
270-0000-43201
0
$570.00
$0.00
PAID BY
- METHOD `
RECEIPT#rt
F�'``CHECK #
'CLTD BY,.
Total Paid forART IN PUBLIC PLACES - AIPP: $570.00 $0.00
. DESCRIPTION
ACCOUNT
QTY-
; :AMOUNT r,``
PAID e.
PAID DATE,
BSAS SB1473 FEE
101-0000-20306
0
$9.00
$0.00
PAID BY ' ' ' .
' . METHOD
r` RECEIPT:#
CHECK# ` 4
CLTD BY ,
Total Paid for BUILDING STANDARDS ADMINISTRATION BSA $9.00 $0.00
` ' c DESCRIPTIONW. a ;';:.
ACCOUNT •
QTY ,
; ' •.;. AMOUNT P+
" PAID.
PAID DATE..
DEVICES, ADDITIONAL
101-0000-42403
0
$285.66
$0.00
PAID -BY _-�
_.
"METHOD'.-, .
RECEIPT# y
CH ECK #
aCLTD BY .
Total Paid forELECTRICAL: $285.66 $0.00
:DESCRIPTIONi `'
ACCOUNT,
QTY
< ,,: AMOUNT,.,.---:'-
" PAID
PAID DATE
AIR HANDLER
101-0000-42402
0
$35.75
$0.00
PAID -BY
"METHOD j :,ti
-RECEIPT•#
- CHECK #
CLTD BY
i' DESCRIPTION "
.�',ACCOUNT'.
QTY
AMOUNT .
PAID ,''
_ ..
•PAII)tDATE
APPLIANCE REPAIR/ALTERATION
101-0000-42402
0
$11.92
$0.00
.PAID BY
(. - �METHOD�.
RECEIPT # "
-'CHECK# ,,. ;
-CLTD.BY`_
x 'DESCRIPTION 1-
ACCOUNT..„ ,
CITY,
. AMOUNT
� + =_- . `PAID ,. s
"PAID DATE.
VENT FAN
101-0000-42402
0
$11.92
$0.00
PAID BY ;,°
, METHOD r
j
; RECEIPT;# ' -•
m CHECK #
CLTD BY
Total Paid forMECHANICAL: $59.59 $0.00
DESCRIPTION ::. "''�
i ,' ACCOUNT
' QTY
AMOUNT:.:
` :PAID)
PAID DATE
FIXTURE/TRAP
101-0000-42401
0
$83.44
$0.00
PAID BY '• ,+ '_' i'' ,.
' ,; ",.:METHOD ` `
Fr R RECEIPT #'
', CHECK;# ' .,-
CLTD BY`
DESCRIPTION :- . _ _
,-
, '. "ACCOUNT ;'
QTY
_ AMOUNTµPAID_-
PAID DATE.
WATER HEATER/VENT
101-0000-42401
0
$11.92
$0.00
P PAID:BY r
:� #
' METHOD
`• 'RECEIPT #
i^ ,3 r
` . CHECK!#
t CLTD BY .'
a�
` sDESCRIP,TION = ,.
` ACCOUNT
QTY
=''° AMOUNT
- PAID
;PAID DATE
WATER SYSTEM INST/ALT/REP
101-0000-42401
0
$11.92
$0.00
PAID -BY
yMETHOD
_ RECEIPT# ;!
„CHECK# F _'
CLTD BY
0
Total Paid for PLUMBING FEES: $107.28 $0.00%
-=` .DESCRIPTION �� ,` '
'' r-ACCOUNTz`
QTY
'' AMOUNT
: ` �PAIDF^' 'r'
,PAID DATE
REMODEL, EA ADDITIONAL 500 SF
101-0000-42400
0
$110.55
$0.00
f 4. PAID BY ':: -�
; METHOD"
s %RECEIPT#
f CHECK#
CLTD'BY
;DESCRIPTION.''
QTY
T
' AMOUNT
RAID
PAID DATE
REMODEL, EA ADDITIONAL 500 SF.PC
101-0000-42600
0
$102.96
$0.00
' ' PAID BYE
Wiz; n METHOD
:.RECEIPT'# ..
CHECK,#
LTD BY
DESCRIPTION - . _„ r <
' ACCOUNT,`QTYP
' " AMOUNT "s
a
PAIDPAID
DATE
REMODEL, FIRST 100 SF
101-0000-42400
0
$48.62
$0.00
.� PAID BYMETHOD'.
RECEIPT# '
CHECK# a�
CLTD BY;"
.DESCRIPTION
ACCOUNT
CITY
"s AMOUNT ' k
y
PAID
PAID„DATE
REMODEL, FIRST 500 SF PC
101-0000-42600
0
$132.99
$0.00
" PAID -BY s:
METHOD
_ 'RECEIP.T # { �'-
_ K
CHECK # ,
�.
CLTD BYr,
Total Paid for REMODEL: $395.12 $0.00
TOTALS:00
0
DESCRIPTION•
QTY
PAID
PermitTRAK6.65
,RG -14 368-,; Address:,45280 SEELEY. DR
�,,
'J# 604630053� , -
1,426.651,
ART -IN PUBLIC PLACES- AIPP = -
+ �' #
r'= �,-
� $570.00
ART IN PUBLIC PLACES - COMMERCIAL
REMOD
270-0000-43201
0
$570.00
E BUILDING STANDARDS ADMINISTRATION $SA=
" ` r; ;a
$9.00,1
BSAS SB1473 FEE
101-0000-20306
0
$9.00
fi ELECTRICALS . t
- -
„$z 85.66
DEVICES, ADDITIONAL
101-0000-42403
0
$285.66
i MECHANICAL • -
? •..
_ , ..
�.c � � .
� 959
$5
APPLIANCE REPAIR/ALTERATION
101-0000-42402
0
$11.92
AIR HANDLER
101-0000-42402
0
$35.75
VENT FAN
101-0000-42402
0
$11.92
PLUMBING.FEES
..x :�-
. :
$107.28
WATER HEATER/VENT
101-0000-42401
0
$11.92
WATER SYSTEM INST/ALT/REP
101-0000-42401
0
$11.92
FIXTURE/TRAP
101-0000-42401
0
$83.44
. REMODEL
$395.12'
REMODEL, FIRST 500 SF PC
101-0000-42600
0
$132.99
REMODEL, EA ADDITIONAL 500 SF
101-0000-42400
0
$110.55
REMODEL, FIRST 100 SF
101-0000-42400
0
$48.62
REMODEL, EA ADDITIONAL 500 SF PC
101-0000-42600
0
$102.96
TOTAL
Date Paid: Friday, July 11, 2014
Paid By: GREEN TOWNE INC
Cashier: PJU
Pay Method: CHECK 7319
Printed: Friday, July 11, 2014 2:51 PM 1 of 1
RWIZ V.CiF AA C