BSPN2014-000878-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
Property Address:
APN:
Application Description
Property Zoning:
Application Valuation:
T,d,y,, 4
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING PERMIT
BSPN2014-0008
79485 HIGHWAY 111 STE 11
600020027
ELECTRICAL RELEASE
Applicant:
IVAN/DONNA SAMUELS INC DBA IVA
80150 HIGHWAY III UNIT A 2
INDIO, CA 92201
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:
Contractor:
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 allege
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.).
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.).
�) I am exempt under Sec. B.&P.C. for this reason
ate: Owner
CONSTRU N LENDIN 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:
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 7/10/2014
Owner:
POLSTAR, LLC
5557 CENTINELA AVENUE
LOS ANGELES, CA 90066
Contractor:
OWNER/BUILDER
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 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 Sectio 3700 of the abor Code, I shall forthwith
comply with those provisions.
�e: O Applicant:
WARNING: FAILURE TO SECURE WORKER 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.
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 agiees 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 ciAenter e above-
ryrentione propertyforinspection purposes.
/Date: V Signature (Applicant or Agent)-
City. of, La Quints
BuikUpg 8r Safety Division
P.O. Box 1504,78-495 Calle Tampico
La.Quinta, G4 92253 -:(760) 777-7012
Building Permit Application and Tracking Sheet
Permit # / f
040100P
Project Address:� I cS I I
Owner's Name:.k
L�C`-
A. P. Number. .. (�� a
Address: C�s- 7 ci 1 1 P Z A' u(;:
Legal Description:
City, ST, Zip:LO S Agcisza A
Contractor.
�7
Telephone: 2-710 %
Project Description:
Address:
City, ST, Zip:
Q)) L Ate-7
i✓Y
Telephone: ,.
State Lic. # : City Lie. #,
Arch, l3ngr., Designer.
Address:
City., ST, Zip:
Telephone:
State Lia #:
Name of Contac t Person: =v p*3 50 L>,..5
Construction Type:. Occupancy:
Project type (circle one): New Add'n Alter Repair Demo
Sq.Ft.: i Q�
# Stories: 1 #Univ t
Telephone # of Contact Person: 7 4-1 � Q �SO Z
Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS UNE
M
Submittal
Req'd
"Rev'd
TRAC MG
PERMITFEES
Plan Sets
Pian Check submitted
Item Amount
Structural Calcs.
Reviewed, ready for cortections
Plan Check Deposit. .
Truss Cabs.
Called Contact Person
Plan Check Balance-
Title 24 Calm
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2id Review, ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S bLL
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
''d Review; ready for correctionslissue
Developer Impact Fee
Planning Approval
Called Contact Person
A.LP.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees