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04-5955 (ELEC)4 BUILDING & SAFETY DEPARTMENT P.O. Box 1504 (760).777-7012 78-495 CALLE TAMPICO FAX (760) 777-7011 LA QUINTA, CALIFORNIA 92253 INSPE;CT,ION REQUESTS (760) 777-7153 BUILDING PERMIT Application Number 04-00005955 �~ Date 8/17/04 Property Address '--78275 CALLE TAMPICO APN: 770-130=001- - - Application description ELECTRICAL Property Zoning . . MAJOR COMMUNITY FACILITY Application valuation . 600 Owner Contractor CITY OF LA QUINTA "NATIONAL CONSTR RENTALS, INC.' C/O AKLUFI & WYSOCKI 15319 CHATSWORTH STREET 3403 10TH ST STE 610 MISSION HILLS. CA 91345. RIVERSIDE CA 92501 WCC: DOUGHTERY CO WC: TRJUB4197201 05/01/05 CSLB: 687160 04/30/06 CCC: C.10 -C13 -C61 -D31 Permit . . . ELEC-MISCELLANEOUS Additional desc Permit Fee . . .45.03 Plan Check'Fee 11.25 Issue Date . . Valuation 0 Qty Unit Charge Per Extension BASE FEE 15.0 1.00 15.0000 EA ELEC,TEMPORARY POWER POLE 15.0D 2.0.0 7.5000.EA ELEC TEMP SUB POLE 15.0D Special Notes and Comments TEMP POWER POLE, •2 SUB POLES Fee summary Charged Paid Credited ----------------- ---------- ---------- --- ------ Permit Fee Total 45.00 . 00 . , 00 O� 4 �. 0, Plan Check Total 11.25 .00 00 '.2 Grand Total 56.25 .00 P.O. BOX 1504 • '�C��� VOICE (760) 777-7012 78-495 CALLE TAMPICO FAX (760) 777-7011 LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153 BUILDING & SAFETY DEPARTMENT f / Application Number: Applicant: Applicant's Mailing Address: Architect or Engineer: Architect or Engineer's Ad Lic. No.: BUILDING PERMIT DECLARATIONS Date: 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 License is a full force and effect. License Class License No. Date Contractor OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I a ex rom the Contractors' State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any I hereby affirm under penalty of perjury that I aLe.Smo 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 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 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 contractor(s) 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 which this permit is issued. I have and will maintain Or compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issu My worke c pensation insurance caoli_c um er /c / Carrier Policy Numbed /�, ) / ! ��< -, _ I certify that, in the performance of the work for which t is OWnit is issued, I shall not employ any perso in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I ecome subject to the workers' Co tion provisions of Section 3700 of the Labor Code, I shall forthwith c ply with those provisions. Date Applicant WARNING: FAI RE TO SECURE WORKERS' NSATION 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. 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 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 work being performed under or following issu a of this permit. 2. Any permit issued as a result of this application becomes and voi 'f work is not commenced within 180 d om date of issuance of such permit, or cessation of work for 180 days will subject permit to ca ellation. I certify that I have read this.application and state that the abov information is co ect. I agree m wit c' nd county ordinances and state laws relating to building construction, and h eby a horize representatives of this co ty to enter upon above- n ' y f nspection purposes. Date Signature (Applicant or Agent):