04-4782 (ELEC)r
La� •�
Tar
BUILDING & SAFETY DEPARTMENT
Box 1s04 c- •:� (760).777-7012
C�MOF.� 8 95 CALLE TAMPICO k
Q��yTA FAX (760) 77.7-7011
C1�NCEpEPT UINTA, CALIFORNIA 92253 INSPECTION REQUESTS (760) 777-7153
BUILDING PERMIT
Application Number . . . 04-00004782; Date ' 6/04/04
Property,'Addr'esV .�7-93-75HI-GHWAY 111
APN: 649-030-999-5 -30420 -
Application description . . . ELECTRICAL
Property Zoning . . . . . . REGIONAL COMMERCIAL
Application valuation .ti 2000, ,
Owner
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STAMKO DEV CO
C/O PROVIDENT FINANCIAL MGMT
10345 W OLYMPIC BLVD 2 FL
LOS ANGELES CA 90064
Contractor
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RIGHTWAY TEMPORARY POWER
653 WEST MINTHOR STREET
LAKE ELSINORE CA 92530
(909) 674-8608
WCC: STATE FUND
WC: 1641639 06/30/04.
CSLB: 388271 01/31/06
CCC: C10
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Permit . . ELEC-TEMPORARY POWER
Additional desc
Permit Fee 45.00 Plan Check Fee .00
Issue Date . . . . Valuation . . . . 0
Qty Unit Charge Per_ Extension
C BASE FEE 15.00
1.00 15.0000 EA ELEC TEMPORARY POWER POLE 15.00
2.00 7.5000 EA ELEC TEMP SUB POLE 15.00
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Special Notes and Comments 4
TEMP POWER, 1 RISER POLE, 1 SERVICE- "
POLE, 1 SRINGER POLE
Fee summary Charged Paid' Credited - Due
----------------- ---------- --=------- ---------- ----------
Permit Fee Total 45.00 .QO .00. 45.00
Plan Check Total .00 .00 11.00 .00
Grand Total 45.00 .00. .00 45.00
P.O. BOX 1504 _
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: 014 -
Applicant:
Applicant's Mailing Address;
BUILDING & SAFETY DEPARTMENT I'
Z
VOICE
FAX
INSPECTIONS
Date: (E
Architect or Engineer: '' �' C
tArtrnneci or tnglneer's Address:
Lic. No.
BUILDING PERMIT DECLARATIONS
(760)777-7012
(760)777-7011
(760);777-7153
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisio sof Chapter 9 (cpmmencang with Section 7000) of Division 3 of the Business and Professionals
/Code, and my nse7i full force and effect.- _7 .
LicensBClass — �enseNo. l
r _ .
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 1, 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 hi 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 contractors) 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 .I ave aU_�
ill mati n insurance, asrequired by Section 00 of the Labor Code, for the performance of the work for which this pertnil is
ywoan rn carrieran olicyn rrartierNumber J
that, in the performance of the work for which this 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.
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 ($100,000), IN ADDITION TO THE COST OF COMPENSATION,, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
I herebyaffirm under CONSTRUCTION LENDING AGENCY
penalty of perjury that there is a construction lending agency for the performanceof the work for which this permit is issued (Sec. 3097, Civ. C.).
Lenders Name
Lender's Address
IMPORTANT Application is hereby made to the Director of BuildingAPPLICANT
CA
Safety for ACKNOWLEDGEMENT
t.
Each Person upon whose behalf this application is made, each person at whose request and to eforhose benefit work stions and restrict np IS et frtnrt under or pursuaica nt to an
issued as a result of this application, the owner. and the applicant. each agrees to, and shall, defend. indemnity and hold harmless the City of Le Quints, its
anypermitofficers, agents and employees for any act or omission related to the work being perfommed 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 applicatiori and state that the above information is co7d. I agree to comply with all city and county ordinances and state laws relating to building
construction nd hereby authorize representatives of this county to enter upon above-mentioned property for inspection purposes.
/date ignature (Applicant or Agent):