BELC2016-008178-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
BELC2016-0081
Property Address:
81600 AVENUE 58
APN:
764010012
Application Description:
IID
Property Zoning:
Application Valuation:
$10,000.00 •
Applicant:
SERGIO PETERSSON
333 E BARIONI BLVD
' V VOICE (760) 777-7125
FAX (760) 777-7011
DESIGN & DEVELOPMENT DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: 9/15/2016
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: _ License No.:
Date: - r 2- '- 6 . /Contra
OW R -BUILDER DECLEsm
TION
I hereby affirm under penal of perjury that I am pt m the Contractor's State
License Law for the folio ng reason (Sec. 7031.5, ness 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 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
Lender's Address:
Owner: v \
IMPERIAL IRR T N Ta
P 0 BOX 98
IMPERIAL A 253`S�iO
19
Contractor: NTS 4
OWNER BUILDER IID
Llc. No.:
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.vyoyk for which this permit is issued.
-v 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 polity 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 Aould become subject to the
workers' compensation provisions of Section 370 f t e Labor ode, I shall I forth�rth
comply with those provisions. i Z- �/
Date: App it
WARNING: FAILURE TO SECURE WO ERS' COMPENSATION COVEBAIS IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOY TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DO RS ($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 ipfQrmation is correct.
I agree to comply with all city and county ordinances and stat aws lelating to building
construction, and hereby authorize representatives of this ' y to en er upon
above-mentioned property for inspection purposes.
Date: , Z.i" Signature (Applicant or Age
t
s
Date: 9/15/2016
Application Number: BELC2016-0081
Owner:
Property Address: 81600 AVENUE 58
IMPERIAL IRRIGATION DIST
APN: 764010012
P 0 BOX 987
Application Description: IID -
IMPERIAL, CA 92253
Property Zoning:
Application Valuation:' $10,000.00
Applicant:
Contractor:
SERGIO PETERSSON
OWNER BUILDER IID
333 E BARIONI BLVD
IMPERIAL, CA 92253
,
Llc. No.:
----------------------------------------------------------.--i---------------------------------
DeCaili tNSTALLATION-OF 1 DUAL PEDESTAL. MOUNT ELECTRICAL VEHICLE CHARGING STATICH�r&'A*A"(MeSPECS. LEVEL 2 CHARGING STATION
INSTALLATION AT IID FACILITY FOR IID ONLY.
A
' t
t
s
FINANCIAL INFORMATION
DESCRIPTION ACCOUNT . CITY AMOUNT
BSAS SB1473 FEE
101-0000-20306 0 $1.00
Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00
DESCRIPTION
ACCOUNT
CITY
AMOUNT
POWER APPARATUS
101-0000-42403
0
$24.17
DESCRIPTION
ACCOUNT
CITY
AMOUNT
POWER APPARATUS PC
101-0000-42600
0
$24.17
DESCRIPTION
ACCOUNT
CITY
AMOUNT
SERVICES
101-0000-42403
0
$24.17
DESCRIPTION
ACCOUNT
CITY
AMOUNT
SERVICES PC
101=0000-4P600' ° 7 ' "'
" 0
.$'12.09
Total Paid for ELECTRICAL: $84.60
DESCRIPTION
ACCOUNT
CITY
AMOUNT
PERMIT ISSUANCE
101-0000-42404
0
$91.85
Total Paid for PERMIT ISSUANCE: $91.85 •
P.O. BOX. 1504
LA QUIN_tA; CALIFORNIA- 92247-1504
78-495 CA[ LE TAMPICO
LA.QUINTA, CALIFORNIA 92.253
CJJ
BUILDING & SAFETY DEPARTMENT
(760) 777-70.12
FAX (760) 777-7011
PROPERTY WNER'S .PACKAGE
Disclosures &Forms for Owl er-BWers. Applying for Construction Permits
IMPQR� IY t MICE TO PROPERTY OWNER
Dear Property Owner.
An.: application for a building Permit has been .submitted. in your name listing yourself as the builder of the :property
:impFdvements specified at 8 !(00.0 St3 'fb • [Ay ENyE , : Lx Q ul N ra co, q 2:2 s 3
.We are .providing you vgith an Owner -Builder Acknowledgmentand lnforma- tion Verification.Forcn to make you awara:of your.
responsibilities and possible risk you may incur by having tlrispermit•isss led• m your name as the
Owner -Builder. We rv(11 not issue a buiidiug•permit until -yo
Whaveread, initialed your understanding.ef each'provision,
signed, and returned this form to us at our okra, address indicated. An agent of the owner cannot execute this -notice
.unless you, the property owner, obtain the prior approval of the permitting authority.
OV I�CNk?
R'S ACWT:EDO . AND'VERMCATI ON OE Il (iRitiiATIETI�t
DIRECTIONS, -
Read and initial each, statement beta v tesignify you uriddrstand`or verif y th4'-information.
I understand a frequent practice of unlicensed persons is to have the property owner obtain an
Owner-Buider'
building permit that erroneously implies that the property owner is providing his or her own labor and rrraterial pers6nifiy:1, as
an Owner -Builder, may be'held liable and subject to serious. financial risk for any injuries sustained by an unlicensed person
and his or her employees while working on my property. 'My homeowner's insurance may not provide coverage .for those
injuries. I.am willfully acting as.an Owner -Builder and am aware of the limits of my insurance -coverage for injuries to workers
on my property.
GC.2. I understand building permits are not required to be signed by property owners unless they are responsible for the
construction and are. not. hiringaceedContacor.to.assume this responsrbility_ .
6 .3. I.understand as an "Owner -Builder" I am:tiie responsil to:party of eecord ori the perruit I understand that I..may protect
mysel€frons potential financial risk by hiring a licensed C
own. ontractor and having the permit filed in his or her name instead of my
Gr— 4. I understand Contractors are required by law to be licensed and bonded in California and to list their License numbers on
permits and contracts.
G C5.1 uiuderstand if i employ or otherwise engage any persons; other than California licensed Contractors, and the total value
of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer"
under state and federal law.
C7 6, I..understand if I am considered an "employer" under state and federal law, I must register with the state and federal
government, withhold payroll taxes, provide workers' cvmpen' sation disability insurance, and contributeto unem iloyment .
compensation for each "employee:" I" atso understand my failure to abide by these laws may subject me, to serious fiiiancial
risk::.
G 7.. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential
..structures cannot .legally build them with the .intent to offer them for sale, unless all worm is performed by licensed
subcontractors and the number of structuresdoes not exceed four' within any calendar. year, .or all of the work is performed
,under. contract with a licensed general building Contractor.
8. 1 understand as an 0-wner-130der if I sell the property for which this permit is issued, I may be held. liable for any
financial or personal. (.juries : sumked by _any subsequent owners) that, result from any latent construction defects in the
workmanship or materials.
GC 9. 1 understand I may obtain more information regarding my obligations as an "employee from. the Internal' e, Revenue
Service, the United States SmallSmallBusiness Administration, the California Department of Benefit Payments, and.the, California
of Industrial Accidents. I also understand I bray contact the California Contractors' State License Board (CkE6, at I-
8.00.-321-:CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors.
(7 am aware of and consent to an. Owner -Builder building permit applied for in my name, and understand that I am the
party legally and - financially responsible . Cox . proposed construction activity. at the following address:
91600 !;18114 _,,A�J F_ we '-Q vViow.. .-.CAq22 5 ..... .. ....
G C- 11. I agree. ffiat,:as the party legally and financially responsible for this proP osed. construction ac ivity,.I will. abide by all
aP—pt-ica6ie taws and.4,1
requirements that govern Owner=Atdldersas well at eimployen.
C 12. 1 agree to notify 7 no the issuer of this 'form immediately ofanyadditions deletions, orchanges'. wany of the information I
have provided on this form. Licensed contractors are.regu'lited by laws designed to protect the public. If you contract with
:someone who does. not have ar license,.tate Contractors' State License Board may be unable to.assist,you with any financial loss .
you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors way. be,iwcivil. COWL. It is also
..important for. you -to understand that if art u4ticensed.Contractor or employee of that -individual. -or firm is injured while working
on your property, you may be held. liablefordamages.. If you obtain a permit as . Owner -Builder and wish to hire Coriftctors,
-you will* be responsible- for verifying.whetier or - not .-those Contractors are propeAylicensed and the status of`thcif workers'
compensation -insurance coverage,.
Before a building permit can be issued, this form must be completed and signed- by the property owner and returned to
the agency responsible forlsstdftg.tfre
permit. Note. A copy of the -property owner, form nqta�,, or
other verification acceptable to theag
Isbe pre;ented` when. 0-0 p 1s. usued 10--yerift.-thei.property
..lied, to W
owner's signature.
Signature of property owner Date: r
..Note:* The following Authorization Form is required to be completed by the property owner only when designating
an agent of the property owner to apply a construction permit for the Owner -Builder.
AUTHORIZATION OF AGENT TO ACT ON PROPERTY 0WNVK'9'kHAV
Excluding the Notice to Property Owner, the execution of which I understand is my.personal responsibility,_I hereby authorize
-the following Person(0 to act as, MY agen*)V:'apply for, sign; and file the documents necessary. to obtain an, Ownir-Buildet
Permit for my Project. Xnffix'11.41*6%o&V At# D V,� Ped e r f 6 M4.
!I
Scope of Construction Project (or Description of Work)-: CJett-r,.'c Vek.-C re C kwf3 it.5iV,+;0" - op 'Fac.. k17 il
'Project 1,6cation''or Address:' el (000 -56+4 AVenve' LA Qu-ittot -'CA q 125
Name of Authorized Agent: Serjio.. 'Pe-TerSow Tel No .06m) y S 7 G89 I
.'Address ofAuthorized Agent: 333 E. Pcormor:; BIV-61. lmper;a l, CA
1 declare under penalty of perjury that I am the property owner for the address listed above and
.1 personally filled out the above I
infofmatiori and certify its accuracy. Note: A c'(? oif- the driver's U notarization,. or other verification
i -c e owner's drive license, fonn
acceptable: to the agewnwcy is regal '46 When the permit is issued to verify the
p property owner's signature..
Property Owner's Signature: Date: V-1
Bin #
City. of La Quints
Building 8L Safety Division
P.O. Box 1504,70-495 Calle Tampico
La.Qulnta, CA 92253 -:(760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
Project Address: 810, 0 516+4 Av: La CA
Owner's Name:. Iro I r6 stiiop ;C f (1 l
A. P. Number.
Address: 3'2,,3 E. g qro o ff 1 81 V A.
Legal Description:
Contractor. Q W Nte 15V; kat e ( 1A D)
City, ST, Zip: Ir'1 er[t q L to 12251
n : °....
Telephone: `%G o N J % ' G $9 . $ .x !
Address:
Project Description:
City, ST, Zip:
�h S'igl� A` toN o V•V ak QtAe Stwl MvJ h,�,•
Telephone:
{p ':
EjtG�-no �%t�1ic1L G�►qr �� SfiaT1•04 Per
oit AC11.t l Specs LtV G 1 5J;C I Rr i H
State Lie. #:
City Lie. #;
Arch., Engr., Designer.
''► -014 t V1 S'�a�I RZ ` O H a D FA ti I t
Address:
t s Ve,�Aic43 . oral No{•' o+/•
City, ST, Zip:
Q Al;c, V S e ..
Telephone:
:•
Construction Type:. Occupancy: B
State Lic. #:
project type (circle one): N Add'n Alter Repair Demo
Sq. Ft : •-- #Stories: 1 # Units: '
Name of Contact Person:$ Cr 1 o Ptte f S o H
Telephone # of Contact Person: (7 ��. S 7 % to B 9 (
Estimated Valine of Project 10,00()
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Recd
TRACIMG
PERMrr FEES
Plan Sets
Pian Check submitted
Item Amount
Structural CaIcs.
Reviewed, ready for corrections
Plan Check Deposit. .
Truss Calcs•
Called Contact Person
Plan Check Balance
Title 24 Calci.
Pians picked up
Construction
Flood plain plan
Plans resubmitted..
Mechanical
Grading plan
2`. Review, ready for correctionsrissue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.L
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
'^' Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
AJ.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
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TRUST GUARD
104.255.215.12
CITY OF LA QUINTA
BUILDING & SAF\E,T,
TY DEP
APPRED
FOR CONRUCTION
9/7/2016
`I FEATURES
{ • Industry standard SAE -J1772 connector
1 • Underwriters Laboratory (UL) listed
• Outdoor rated enclosure,
• Americans with Disabilities Act (ADA)
compliant installation
• Auto restart in event of power outage
or ground fault
• Breakaway safety cable
• Integrated cable stowage
• Optional network communication module
(EVSE-RS+)
SERVICE AND INSTALLATION'
• Expanding network of independent
certified, trained electricians
• Convenient customer site assessments
and installation
1 .
• 24-hour response time during
business hours
SPECIFICATION
EVSE-RS
Connector
SAE J1772 compliant
Voltage
208VAC to 240VAC
t Frequency
60/50Hz
Output Current
30A max'
Input Current -
40A max
Operating Temperature
-22°F to 122°F
1
-30°C to 50°C
Enclosure
NEMA 3R
Regulatory Compliance
UL; cUL, CE, CTick listed
• inio:marion ar:dsp�rO.carons subject to'
change
02011 Aero\Aronff a t, Inc
17.0111.10149
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CITY OF LA QUINTA
BUILDING & SAFETY DEPT._
I FOR CONSTR CTION
ITE
& s@ C E
C
SITE PLAN
IMPERIAL IRRIGATION DISTRICT
J-71 BUILDING
INSTALLATION OF ONE (1) DUAL PEDESTAL MOUNT ELECTRIC VEHICLE CHARGING STATION
❑ DD
SCALE: NTS
I
CITY OF LAQUINTA
BUILDING & SAFETY DEPT.
APPR VED
FOR CONST UCTION
DATE 146 A - - I
PROJECT
LOCATION
OPERATIONtYBUILDING
111111 IIIhf�� II
EMPLOYEE PARKING
58th AVENUE
° lit.
�cPRE T�
- LOCATIO
,tk` ` i • 1
mil i.e at,a e
r • IL
fine
B tIII cIII vole
PUBLIC PARKING
1�P
NpM•
I;
�' .
58th AVENUE
° lit.
�cPRE T�
- LOCATIO
,tk` ` i • 1
mil i.e at,a e
r • IL
1�P
NpM•
I;
�' .
VICINITY MAP
SCALE: NTS
SCOPE OF WORK:
IID TO INSTALL ONE (1) DUAL PEDESTAL MOUNT
ELECTRIC VEHICLE CHARGING STATION PER ATTACHED
SPECIFICATIONS. THE LEVEL II ELECTRIC VEHICLE
CHARGING STATION WILL BE INSTALLED INSIDE OF IID
FACILITY AT THE EMPLOYEES PARKING LOT AND THEIR
USE SHALL BE FOR IID VEHICLES ONLY (NOT FOR PUBLIC
USE).
a
0
0
4
N
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Y YY 11i �1
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SEP 15 2016 W
CITY OF LA QUINTA
COMMUNITY DEVELOPMENT
SHEET __L_ OF_3
x
E EXISTING 200 AMP, 3 0
a
120/208 PANEL
'T-. MAIN
POWER I
MEN KERS PANEL
MEN
NEW 1%" CONDUIT RUN;
4 - #8 AWG THHN COPPER,
EXISTING 24" x 24" x 8" 1 - #10 AWG THHN COPPER
PULL BOX IT
ENTRY STORAGE
HALLWAY CLERICAL
'':SCHEDULER II TECH. Tryli SUPT. ENERGY
C. & M.
NEW 1Y4" CONDUIT RUN; I.T. DEPT. DISPATCH CENTER
4 - #8 AWG THHN COPPER, ELE DISTRIB
1 - #10 AWG THHN COPPER WOMEN CLERICAL OUTAGE COORD
TECH.
w CONSTRUCTION $ MAINTENANCE
V
p STORAGE ! FS
SHIFT R ■
0 SHIFT ROOM
wssisr. suvuRRr.
WT. RES. Q DISP.
MTR. RK. BREAK TELE AND SCADA
SUPT. GRAIL. CONFERENCE
METER STORAGE CONSTR. MAINT. AREA SUPT. CONSTR. ROOM EQUIP. RM.
BRG RM. JANITOR A C UNIT wl�' L0' MAINTENANCE
� XEROX SCHEDULER H ■
F-.... USE
NEW 12" x 12" x 4" '
PULL BOX
• - VACANT LINE CONST, POWER STAND ■
FOREMAN BY SYSTEM
STORAGE MEN
WOME
TRAINING
ROOM
NEW 1%4' CONDUIT RUN;
4 #8 AWG THHN COPPER,
Z
1 - #10 AWG THHN COPPER ASSEMBLY AND TRAINING STORAGE ■
LOBBY
STOR:. STOR. TROUBLE
SHOOTERS
METER SHOP OFFICE
NEW 12" x 12" x 4" F M 1A6.
PULL BOX METER TECH.
VESTIBULE FOREMAN ,
■
NEW 3/4" CONDUIT RUN; A '
4 - #8 AWG THHN COPPER, / v
1 - #10 AWG THHN COPPER
EXISTING COLUMN
NEW DUAL PEDESTAL MOUNT ELECTRIC
VEHICLE CHARGING STATION (LEVEL II)
CITV
BUILDING &SAFETY DEPT.'
IMPEL
FOR CONS UC T ION gl
ELECTRICAL PLAN - LINE DIAGRAM
B
q f��6 8,600
SCALE: NTS -- -- oaran mE�mm1
5R� n aaE_
om®n aaE_
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SHEET _? _ Of_ 3
NEW 1Y4" CONDUIT R
4 - #8 AWG THHN COPP
1 - #10 AWG THHN COPE
EXISTING 24" x 24" x 8
PULL BO;
NEW 12" x 12" x 4" NEW 12" x 12" x 4"
PULL BOX PULL BOX
1
C�C."( OF LA QUINTA
- DING'& SAFETY DEPT.
APPROVED
CONSTR CTION
� f BY
o.,, ... ! rsul
NEW DUAL PEDESTAL MOUNT ELECTRIC
VEHICLE CHARGING STATION (LEVEL II)
U
a
SHEET _3_.OF_ 3