ELEC (04-7067)BUILDING & SAFETY DEPARTMENT
P.O. BOX 1504 (760).777-7012
78-495 CA LLE TAMPICO FAX (760) 77.7-7011
LA QUINTA, CALIFORNIA 92253 INSPECTION REQUESTS (760) 777-7153.
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BUILDING PERMIT
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CITY OF LA QUINTA
FINANCE DEPT
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Application Number
04-00007067 Date 1.1/04/04
Property Address . ...
. . 52320 AVENIDA NAVARRO
APN:
773-275-003-20 -0'00000--
Application description
ELECTRICAL
Property.Zoning . . .
. . COVE RESIDENTIAL,.
Application valuation
1500
Owner
Contractor
-- - - - - - - - - - - - --
M/M CLARK
MIRAGE ELECTRIC
52320.AVENIDA NAVARRO
'19400 FORD AVENUE
LA QUINTA. CA 92253
DESERT HOT SPRINGS
CA 92,241
('760) 408-3125
WCC: STATE FUND
WC: 174497003
12/01/04
CSLB: 536093
07/31/06,
CCC: C10
Permit ELEC-SERVICE
CHANGE
Additional desc
Permit Fee
33.50 Plan Check Fee
.00
Issue Date . . . .
Valuation
0
Qty Unit Charge Per
Extension
BASE FEE
15.00
----_---1_00-------185000-EA
ELEC,SVC <=600V/<=2j0A
- 18.50
Special Notes and Comments
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- - - - - - - - - - - - -
200 AMP ELECTRICAL SERVICE
CHANGEOUT
Fee summary- Charged
Paid Credited
Due
Permit Fee Total 33.50
.00 .00•
33.50
Plan Check Total
.00 .00 .00
.00
Grand Total 33.50
.00 .00
33.50
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CITY OF LA QUINTA
FINANCE DEPT
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P.O. BOX 1504 •
VOICE (760) 777-7012
78-495 CALLS TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
s s
Application Number:
Applicant:
Applicant's Mailing Address:
Date:
Architect or Engineer:
Architect or Engineer's Address:
Lic. No.:
BUILDING PERMIT DECLARATIONS
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 Professionals
Code, and my Licenses v� full f rc d effect. (�
® License Class_ ®License No. ��C 3
mate tractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors' 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 Contractors' 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).):
U 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 or 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.).
U 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.).
U I am exempt under Sec. BA P.C. for this reason
Date Owner
WORKERS' 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 w ers' compensation insurance, as requir d by ction 3700 of the Labor Code, for the performance of the work for which this permit is
co sation insurance carrier a I' r u r
*amer olicy Number 0c)
_ I certif tat, in th6 performance of the work for which is pe t is is ued, 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 should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall
forthwith comply with those provision
Date///V/0 ®Applic t
WAR ING. FAILURE TO SECURE WORKERS' COM NSATION 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.
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
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 pe ormed under or following issuance of this permit.
2. Any permit issued as a result of this application becomes null and void if work is n 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 a ee to comply with all city and county ordinances and state laws relating to building
constru/ction,(ad her by authorize representatives of this county to enter up above entioned property for inspection purposes.
Date ` / / Signature (Applicant or Age ):