12-0331 (ELEC)F.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
T4'!t 4 4 Q"
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Application Number:X12=0"00003.3--1—;
WORKER'S COMPENSATION DECLARATION
Owner:
Property Address:
5-4-1`45 AVENIDA JUAREZ
DALE BERMAN
APN:
774-193-019-7 -000000-
54145 AVENIDA JUAREZ
Application description:
ELECTRICAL
LA QUINTA, CA 92253
Property Zoning:
COVE RESIDENTIAL
I hereby affirm under penalty of peri that I am exempt from the Contractor's State License Law for the
Application valuation:
250
_ I certify that, in the performance of the wprltlor which this permit is issued, I shall not employ any
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the
m sub ct to the rkers' compensation laws of California,
person in any man"bec
Contractor:
Applicant:
Architect or Engineer:
JCB SOUTHWEST ELECTRIC CO I
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).:
1 scant: ,
PO BOX 13466
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. the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The
PALM DESERT, CA 92261.
Contractors' State License Law does not apply to an owner of property who builds or improves thereon,
SUBJECT AN EMPLOYER TO CRIM AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
(7GO)345-0094
DOLLARS ($100,000). IN ADDITITHE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
f ^
LiC. No.: 750740
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.).
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 3/29/12
D!A H
MAR 2 2012 Ei
11,
A QUINTA
--------------------------------------------------------------------------------------=-----------
LICENSED CONTRACTOR'S DECLARATION
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with
I hereby affirm under penalty of perjury one of the following declarations:
Section 7000) of Division 3 of the Business an r essionals Code, and my License is in full force and effect.
_ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided
Licens�rass: CIO - No.: 750740
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
4�5'cense
/. _ -)
ate: 1 C tractor:
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
OWNER -BUILDER DECLARATION
insurance carrier and policy number are:
I hereby affirm under penalty of peri that I am exempt from the Contractor's State License Law for the
Carrier PREFERRED EMPLY Policy Number WKN134436
following reason (Sec. 7031 .5, Business and Professions Code: Any city or county that requires a permit to
_ I certify that, in the performance of the wprltlor which this permit is issued, I shall not employ any
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the
m sub ct to the rkers' compensation laws of California,
person in any man"bec
permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State
and agree that, if Iubje orker, compensation provisions of Section
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
3700 of the Laborhwith comply with those provisions.
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).:
1 scant: ,
1 _ 1 I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and
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. the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The
ERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
WARNING: F LU/0 RE TO SECUREVNPENALTIES
Contractors' State License Law does not apply to an owner of property who builds or improves thereon,
SUBJECT AN EMPLOYER TO CRIM AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
and who does the work himself or herself through his or her own employees, provided that the
DOLLARS ($100,000). IN ADDITITHE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
improvements are not intended or offered for sale. If, however, the building or improvement is sold within
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
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.).
APPLICANT ACKNOWLEDGEMENT
(_) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the
7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of
conditions and restrictions set forth on this application.
property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed
1. Each person upon whose behalf this application is made, each person at whose request and for
pursuant to the Contractors' State License Law.).
whose benefit work is performed under or pursuant to any permit issued as a result of this application,
(_ 1 I am exempt under Sec. , B.&P.C. for this reason -
the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City
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
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 info doandh
ect. I agree to comply with all
city and county ordinances and state laws relating to b ' g con ruc on,by authorize representatives
of this county to enter upon the above-mentioned pro erty r i ti
Bate: 3� 3"� Sig ure (Applicant or Agent):
LQPERMIT
Application -Number . . . . . 12-00000331
Permit . . . ELEC-MISCELLANEOUS
Additional desc . .
Permit Fee . . . . 16.50 Plan Check Fee
.00
Issue Date . . . . Valuation . . .
. 0
Expiration Date 9/25/12
Qty Unit Charge Per
Extension
BASE FEE
15.00
2.00 .7500 PER ELEC DEVICE/FIXTURE 1ST 20
1.50
----------------------------------------------------------------------------
Special-Notes and Comments
PERMIT TO RESOLVE CODE CASE #11-2010.
INSPECT 2 LIGHT FIXTURES INSTALLED ON
PATIO STRUCTURE. OK PER S. TRAXEL. CODE
OFFICER E. ESCATEL
-----------------------------------------------------------------------=----
Other Fees . . . . . . . . BLDG STDS•ADMIN.(SB1473)
1.00
Fee summary Charged Paid Credited
----------
Due
-----------------
Permit Fee Total 16.50 .00 .00
16.50
Plan Check Total .00 ..00 .00
.00
Other Fee Total- 1.00 .00 .00
1.00
Grand Total 17.50 .00 •.00
17.50
LQPERMIT
of. Qui�1b
`BulkAng a Safety Division .
P.O. Box 1504,78-495 Calle Tampico,
La,Quinta, CA 92253 -:(760) 777-7012
Building Permit Application• and Tracking Sheet
Permit # '
Project Address:.
Owner's Name:. D1960 -
60-A
A. P. Number
Address:
Legal Description:.
Contractor. C ' �.
/J ' ciOr�/ /►mil �-�iQl
�
City,ST Zip:
Telephone: • " ;�-: �s,,`
�> > �c•:•'-'yam s?ld`,',
Project Description:
/
Address: D k ! (p
City, ST, Zip: `✓`E'-�PO� ��
Telephone:%0- 3 (-x-06
IG.NS " ,-0 � 0
State Lic. # : city Lic. #;
Archy Engr., Designer.
�.Y��,��5
Address:
City., ST, Zip:
Telephone:
State Lic. #: ~y'
Name of Contact Person:Sq.
Construction Type:. Occupancy:
Project type (circle one): New Add'n Alter Repair Demo
Ft : # Stories:
# Units:
Telephone # of Contact Person:
Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Recd
TRACIGNG
PERMIT FEES
Plan Sets
Pian Check submitted.Item
Amount
Structural Calm
Reviewed, ready for corrections
Plan Check Deposit. .
Truss Calm
Called Contact Person
Pian Check Balance,
Title 24 Cities.
Pians picked up
Construction
Flood plain plan
Plans resubmitted..
Mechanical
Grading plan
2' Review, ready for correctiomAssue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
It
S.M.L
H.O.A. Approval
Plans resubmitted
Grading
rN HOUSE:-
Review; ready for corree6an&rmue
Developer Impact Fee
Planning Approval.
Called Contact Person
A;LP,P, "
Pub. Wks. Aper
Date of permit issue
School Fees
Total Permit Fees