04-6619 (ELEC)Tilf °F 4 Q"
BUILDING & SAFETY DEPARTMENT
P.O. Box 1504 (760).777-7012
78-495 CALLS TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTION REQUESTS (760) 777-7153
BUILDING PERMIT
Application Number . . . . .. 04-00006619 Date 10/05/04
Property Address . . . . . . 51865 AVENIDA'CORTEZ
APN: 773-152-025-7 -000000-
Application-description . . . ELECTRICAL
Property Zoning . . . . . . COVE RESIDENTIAL
Application valuation . . . . 1000
Owner Contractor .
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GOODMAN'JAY HEGGE ELECTRICAL CONTRACTORS
P 0 BOX 25 P.O. BOX 1365
LA QUINTA CA 92253 LA QUINTA CA 92247
WCC: STATE FUND
WC: 0461118304 01/01/05
CSLB: 748171 04/30/06
CCC: C10
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Permit . . . . . . ELEC-SERVICE CHANGE.
Additional desc .
Permit Fee . . . . 33.50 Plan Check Fee .00
Issue Date . . . . Valuation . . . . 0
Qty Unit Charge Per Extension
BASE FEE 15.00
1.00 18.5000 EA ELEC SVC <=6OOV/<=200A 18.50
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.Special Notes and Comments
UPGRADE SERIVE TO 200.AMP
Fee summary Charged Paid Credited Due
Permit Fee Total 33.50 .00 .00 33.50
Plan Check Total . .00 .00 .00 .00
Grand Total 33.50 .00 .00 33.50
P.O. Box 1504 "
VOICE (760) 777-7012
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 9225344 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number: O
Applicant:
Applicant's Mailing Address:
Date: l a
Architect or Engineer:
Architect or Engineer's Address: / J A
Lic. No.:
BUILDING PERMIT DECLARATIONS
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 Professionals
Code, and my Licenge s in full force and effect. �/
License Class C
Date Contractor �1
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Can tractors' State License Law for the tol lowing reason (Sec. 7031-5, Business and Professions Code: Any
city or ccunly that requires a permit to construct, alter, improve, demolish, or repair an y structu re, 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 mare than five hundred dollars (MC),):
(_) 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' Stale License Law does not apply to an owner of property who builds or Improves thereon, and who does the work
himself or herself at 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 compietlon, the owner -builder will have the burden of proving that he or she did not bulid or improve for the purpose of sale,),
U I, as owner of the property, am exclusively contracting wish 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 ccntraatgr(s) I[censed pursuant to
the Contractors' State License Law.).
�} am exempt under Sec. , BA P.C. for this reason
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 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
�i ue w rker 'cam ensation insurance carrier an ❑ I y numr ar�:
Carrier rf licy Number
�� certif that, in the performance of the work for which this permit is issued, I sh ll not employ any person in any manner so as to become subject to the workers'
campensatian laws of California, and agree at, if I should become su 'ect to the workers' compensation provisions of Section 3700 of the Labor Code, I shall
(/J/�) t�rthwith comply with those provisions.
Date ` v J 0 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 ($100,000). iN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
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
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 raquest and for whose benefit work is performed under or pursuant to any permit
Issued as a result of this application, the owner, and t h a applicant, each agrees to, and shall, defend, indemnify and hold harmless the City of La Quinta, its
officers, agents an.d employees for any act or omission related to the work heIng performed under arfollowing 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 perrhlt to cancellation.
i certify
that I have read this application and state that the above Information is correct. I agree to comply lith all city and county ordinances and state laws relating to building
constr/uction, arid hereby authorize representatives of this county to enter up bove-m lion ed pro rty for inspection purposes.
Date `� vJ
Signature (Applicant or Agent):