12-0838 (ELEC)4'
P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: 12-00000838
Property Address: 78998 MILES AVE
APN: 604-032-026- - -
Application description: ELECTRICAL
Property Zoning: MAJOR COMMUNITY FACILITY
Application valuation: 10000
Applicant: Architect or Engineer:
�. ,�
V
LICENSED CONTRACTOR'S DECLARATION
•4
�W
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
1 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 License is in full force and effect.
License Class: - - - - - - ---- t LicenseNo.: A -13-C10
Date: !$ Contractor:
C. 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 th_e
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 7.031.5 by
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
(_) 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, 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: 1
LQPERMIT
Owner:
FAMILY HERITAGE CHURCH
78998 MILES AVE
LA QUINTA, CA 92253
Contractor: D
JITNEY COMPANY INC
1057 EAST IMPERIAL HWY,�
PLACENTIA, CA 92670 '
WCC: STATE INS FUN
LiC. No.: A -B -C10
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 3/18/13
M��1�Zo,
3 /Am r1,4 a,,.,_
------------------------------- - - - - - - ---------
WORKER'S COMPENSATION DECLARATION
I hereby affirm under.pehalty 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
ssued.
AVh ive 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 902208612 09/15/19olicy Number 719304
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.
F - .Date: ! /' Applicant:-° Z44/ -d
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 ($100,0001. 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 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
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 county to enter upon the above-mentioned property for inspection purposes.
i
DaAgent):
e �J �,/ � ��
Date: 9 / Signature (Applicant or Agent): /L�7/IYL/ /J ,4�c,,Ls
Application Number . . . . . 12-00000838
Permit . . . ELEC-MISCELLANEOUS
Additional desc .
Permit Fee . . . . 51.00 Plan Check Fee
6.50
Issue Date Valuation . .
. 0
Expiration Date 9/14/13
Qty Unit Charge Per
Extension
BASE FEE
15.00
12.00 3.0000 EA ELEC APPLIANCES
36.00
.00 11.0000 EA ELEC MISC
.00
Special Notes and Comments
REPLACEMENT OF T -MOBILE COMMUNICATIONS
EQUIPMENT - (12) EXISTING ANTENNAS TO BE
REMOVED AND REPLACED WITH (6) AIR21
PANEL AND (3) TMA ANTENNAS REUSING
EXISTING MOUNTING APPARATUS AND MONO
PALM. 2010 CALIFORNIA BUILDING CODES.
August 31, 2012. 3:57:45 PM AORTEGA
-------------------_------------------------------------•-------
Other Fees . . . . . BLDG STDS ADMIN .(SB1473)
.1.00
Fee summary Charged. Paid Credited
----------
Due
----------------- ----------
Permit Fee Total 51.00 .00 .00
51.00
Plan Check Total 6.50 .00 .00
6.50
Other Fee Total 1.00 .00 .00
1.00
Grand Total .58.50 .00 .00
58.50
LQPERMIT
# 1
City Of La Quin' td
Btdt&g & Safety Division
Permit # P.O. Box 1504,78-495 Calle Tampico
i
La.Quinta, CA 92253 -{760) 777-7012
e pp Ica on an rac Ing Sheet
Project Address: ,
Owne s Name:. i L
A P. Number. O (73 2 Address:
Legal Description: City. ST, Zip: LA a
cAAj
Contractor. �� • / r �G Tdephoae D�j 1j 15
Address: Jr qj// �a hj �tcL Project Description: 2 i
City. ST, Zip: CoU`fG/6icr
r Flo
Telephone: 15 f eq 91 (12J!,. r ' •:
State Lia # : '7! %309' City Lic, 9,
Arch- Eng, Designer �(
Address:
City, ST, Zip: DK
School Fees
— — — I-- �— — Tota! Permit Fees
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-7
- $�cb`tio►Z- � �- �r—,�..,:�.-�c Vic, � - .-_ •
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Telephone: l .p �� �j
State Lic. #: D:
a
Construction Type:. Occupancy:
Project type (circle one): New Add'n ter Repair Demo
Name of Contact Person:
Sq. Ft.: # Stories-
# Unit,s: .
Telephone # of Contact Person:
l . 30k7— O
Estimated Value of ProjeA i7.
APPLICANT: DO NOT WRITE BELOW THIS UNE
d
Submittal
RoWd Recd
TRACKWG PERbW FEES
Plan Sets
Pian Check submitted Item Amount
Strndatai (airs
2
Reviewed, ready for corrections Plan Check Deposit. .
Truss Cala.
Called Contact Person Plaa Check Balance-
Tithe 24 Cates
Plans picked up �I aastraetlon
Flood plain plan
Pians resubmitted.. f1 Mechanical
Grading plan
r! Review, ready for correctio asst {V Electrical
Subeontector List
Called Contact Person $ Plumbing
Grant Deed
Plans picked up ML
H.O.A. Approval
Plans resubmitted Grading
IN ROUSE:-
'`` Review; ready for eorrectlonsrmue Developer Impact Fee
-Caked-Eoutaet-Person
Pub. Wks. Appr
Date of permit issue
-
School Fees
— — — I-- �— — Tota! Permit Fees
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,.4'
-7
- $�cb`tio►Z- � �- �r—,�..,:�.-�c Vic, � - .-_ •
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