09-0080 (ELEC)P.O. BOX 1504 4
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Application Number: 09-00000080 Owner:
Property Address: 49200 COACHELLA DR BRZOZOWSKI FRED W
APN: 646-030-004-1 -000000- 49200 COACHELLA DR
Application description: ELECTRICAL LA QUINTA, CA 92253
Property Zoning: GOLF COURSE (
Application valuation: 6000
Contractor:
Applicant: Architect or E gineer: G & M ELECTRIC OF
V/ 69858 POMEGRANATE
/4CATHEDRAL CITY, C
(760)250-1424
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that 1 am licensed under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and ProfesAonais Code, and my License is in full force and effect.
License Class: C10 License No.: 921456
Date: _Z-01 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 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 1$500).:
1 _ I 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 1, 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.).
(_ 1 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:
LQPERMIT
C
Lic. No.: 921456
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 2/02/09
�DSRT
234FE8 p2 1009 J
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 GUARD INS GROUP Policy Number GMWC009421
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 bject to the workers' compensation laws of California,
and agree that, if I should become subj to the workers' compensation provisions of Section
3700 of the Labor e, I s 11 forthwi comply with those provisions.
Date: 'Z-7-01 Applicant:
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 1$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 cessa on of work for 180 days will subject
permit to cancellation.
I certify that I have read this application and state that the above information correct. I agree to comply with all
city and county ordinances and state laws relating to ilding construction, an hereby authorize representatives
of this county to enter upon the above-mentioned pro y for inspection purp ses.
Date: Z;ol- a1 Signature (Applicant or Agent):
Application Number 09-00000080
Permit . . . ELEC-SERVICE CHANGE
Additional desc .
Permit Fee . . . . 33.50 Plan Check
Fee
.00
Issue Date . . . . Valuation
. . .
. 0
Expiration Date . . 8/01/09
Qty Unit Charge Per
Extension
BASE FEE
15.00
1.00 18.5000 EA ELEC SVC <=600V/<=200A
18.50
----------------------------------------------------------------------------
Special.Notes and Comments
ELECTRICAL SERVICE CHANGE OUT REPLACE
400 AMP WITH NEW 400 AMP.
------------------------------------------------ ----------------------------
Other Fees . . . . . . . . . BLDG STDS ADMIN (SB1473)
1.00
Fee summary Charged Paid Credited
Due
-----------------------------------------------
Permit Fee Total 33.50 .00
----------
.00
33.50
Plan Check Total ..00 .00
.00
.00
Other Fee Total. 1.00 .00
.00
1.00
Grand Total 34.50 .00
.00
34.50
LQPERMIT
02/02/2009 HON 13:02 FAX La Quinta Building/Safty 0001/001
I
Bin # .
City. of La Quinta
Building at Safety Division
Permit # P.O. Box 1504,78-495 Cage Tampico
la Quinta, CA 92253 - (760) 777=7012
Building Permit Application and Tracking Sheet
Project Address: 49 Zpp 9:;l74 4C4011,5644-4 Owner's Naine: M14.13 ,RZO Z0 *4J 5 K 1 'T R V Sr .
A. P: Number: Address: 99— ZOO GOAGHF�Cl�1
A Ir LA
Legal Deset tion:City, ST, Z►P:1a �vNT4 irS ? SS N
. G
Contractor:.61A4 xz-e�ArC- O.'--qwt RA5 Telephone
Address:g54f C:� �- A_AJ Project Description: �.�✓l Jnr G�r�/4tSS—
City, ST, Zip: lam'! - li CA 417-7-3,f v'r /216-- e'A <--e_'
Telephone:(76 a ZSa / 4 ' Zq i✓ I F")_
State Lic. # : .City Lic. #:
Arch., Engt., Designer..
Address:
City, ST, Zip:
Telephone: Construction Type. Occupancy.
State Lic. #: Pro}ca type (circleone): Ntw Add'n Alter JQjD Demo
Name of Contact Person: Gj75AlZ 601--JZ4g�CZ Sq. Ft.: #Stories: ( # Units:
Telephone # of Contact Person: 7� osv i4 �' Estimated Value of Project••. d d
APPLICANT: DO NOT WRITE B&OW THIS UNE
0
Submittal
Plan Sets
Req'd .
.. RWd. ..
TRACIMG PERMITFEES
Pian Check submitted item Amount
Structural Cala.
Reviewed, ready for corrections Plan Check Deposit'
Truss Cales.
Called Contact Person Plan Cheek Balance
Energy Cale.
Plans picked up Construction
Flood plain plan
Plans resubmitted Mechanical
Grading plan
2d Revitw, ready for correctionsfutue Electrical
Subtontaetor List
Called Contact Perron Plumbing
Gnat Deed
Plans picked up S.M.I.
H.O.A. Approval
Plans resubmitted -Grading
IN HOUSE:-
''� Review, ready for correetionsfissae Developer Impact Fee
Plannigg Approval
Called Contact Person A.LP.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees