BELC2016-0053LICENSED 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: CIO / License No.: 904511
Date: v,�C�actor:
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
($500).:
(1 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 ) 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
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
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 Section 3700 of the Labor Code, I shall forthwith
comply with those provisions.
ate: "f w%Aoolicant: _bd ail
J
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 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 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 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 city to enter upon the
above-mentioned property for inspection purposes.
p r_
��: 6� ` 6 nature (Applicant or Agent):
�NMNCl/
VOICE (760) 777-7125
78495 CALLE TAMPICO
DDD D
LA QUINTA, CALIFORNIA 92253
FAX (760) 777-7011
COMMUNITY. DEVELOPMENT DEPARTMENT
INSPECTIONS
(760) 777-7153
BUILDING PERMIT
Date: 6/9/2016
Application Number:
BELC2016-0053
Owner:
Property Address:
54425 AVENIDA VALLEJO
LINDA COPELAND
APN:
774244021
54425 AVENIDA VALLEJO
Application Description:
COPELAND RESIDENCE / ELECTRICAL
LA QUINTA, CA 92253
Property Zoning:
Application Valuation:
$2,000.00
CO�r` Oc�
Applicant:
Contractor:
O6
MENDOZA ELECTRIC
MENDOZA ELECTRIC
F!
op�c'fT/9
50-313 CALLE TOLOSA
50-313 CALLE TOLOSA
`✓
COACHELLA, CA 92236
COACHELLA, CA 92236
IFN
l
•(760)404-7214
---------------------------------------------------------------------------------------------
LIc. No.: 904511
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: CIO / License No.: 904511
Date: v,�C�actor:
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
($500).:
(1 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 ) 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
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
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 Section 3700 of the Labor Code, I shall forthwith
comply with those provisions.
ate: "f w%Aoolicant: _bd ail
J
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 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 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 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 city to enter upon the
above-mentioned property for inspection purposes.
p r_
��: 6� ` 6 nature (Applicant or Agent):
FINANCIAL INFORMATION
DESCRIPTION . - '� �� ACCOUNT ".., K,;" QTY ,' AMOUNTi . ` PAID
PAID DATE
BSAS SB1473 FEE 101-0000-20306 0 $1.00 $1.00
6/9/16
PAID BY` METHOD ".q RECEIPT # ;,CHECK #'
CLTD BY
MENDOZA ELECTRIC DEBIT R16107 BELC2016*0053
MFA
Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00, $1.00
3� �• DESCRIPTION'.
ACCOUNT A' ° ,:
QTY
AMOUNT`"
PAID
PAID DATE.
SERVICES
101-0000-42403
0
$24.17
$24.17
6/9/16
" PAID BY.METH_OD°:RECEIPT
#
CHECK #
CLTD'BY `
MENDOZA ELECTRIC
DEBIT
R16107 .
BELC2016*0053
MFA
r f)ESCRIP,TIOW, , _
t
`;ACCOUNT ;>'
TY
AMOUNT.:
PAID DATE
SERVICES PC
101-0000-42600
0
$12.09
$12.09
6/9/16
P0,16 Bi "
METkIOD F
RECEIPT # t�
- #s
CLTD BY,
yx
_•CHECK
,`
MENDOZA ELECTRIC
DEBIT
R16107
BELC2016*0053
MFA
Total Paid for ELECTRICAL: $36.26 $36.26
DESCRIPTION ¢
ACCOUNT
QTY
AMOUNT{'
PAID '
'PAID DATE''
ti t
'��
PERMIT ISSUANCE
101-0000-42404
0
$91.85
$91.85
6/9/16
PAID BY}" *y
METHOD.
x.RECEIPT #
y CHECK
CLTD BY;
�a
MENDOZA ELECTRIC
DEBIT
R16107
BELC2016*0053
MFA
Total Paid for PERMIT ISSUANCE: $91.85 $91.85
TOTALS:
Description: COPELAND RESIDENCE / ELECTRICAL
Type: ELECTRICAL Subtype: Status:,ISSUED Applied:. 6/9/2016 MFA
Parcel No: 774244021 Site Address: 54425 AVENIDA VALLEJO LA QUINTA,CA 92253 Approved: 6/9/2016 MFA
Subdivision: SANTXCARMELITA VALE LA QUINTA Block': 289 Lot: 10 Issued: 6/9/2016 MFA
UNIT 26
Lot Sq Ft: 0 Building Sq Ft: 0 Zoning: Finaled:
Valuation: $2,000.00 Oc-cupancy Type: Construction Type: Expired: 12/6/2016 MFA
No. Buildings: 0 No. Stories: 0 No. Unites: 0
I
%.VUC
__j Applied to Approved
Approved to. iss6Ek
I
CONDITIONS"
CONTACTS
MAIL
6 9-E,77,
-�.,PH �JAX
SS! =STATE": CITY,
APPLICANT MENDOZA ELECTRIC 50-313 CALLE TOLOSA COACHELLA CA 92216 (760)564-0947
CONTRACTOR MENDOZA ELECTRIC 50-313 CALLE TOLOSA COACHELLA CA 42236 (760)564-0947
OWNER LINDA COPELAND' 54425 AVENIDA LA QUINTA CA 92253 (760)564-0947
VALLEJO
FINANCIAL INFORMATION
. . ... .. .... ......... .... .... ......... .
Printed: Thursday, June 09, 2016 10:42:54 AM 1 of 2
Cffw1,1.51CM4
Details: Crimmut OUT Ur 4UU Alvir ELECTRICAL FAIYCL lu 4UU Alvir rcr% 4UJL3 CALIFORNIA BUILDING
%.VUC
__j Applied to Approved
Approved to. iss6Ek
I
CONDITIONS"
CONTACTS
MAIL
6 9-E,77,
-�.,PH �JAX
SS! =STATE": CITY,
APPLICANT MENDOZA ELECTRIC 50-313 CALLE TOLOSA COACHELLA CA 92216 (760)564-0947
CONTRACTOR MENDOZA ELECTRIC 50-313 CALLE TOLOSA COACHELLA CA 42236 (760)564-0947
OWNER LINDA COPELAND' 54425 AVENIDA LA QUINTA CA 92253 (760)564-0947
VALLEJO
FINANCIAL INFORMATION
. . ... .. .... ......... .... .... ......... .
Printed: Thursday, June 09, 2016 10:42:54 AM 1 of 2
Cffw1,1.51CM4
FINANCIAL INFORMATION
. . ... .. .... ......... .... .... ......... .
Printed: Thursday, June 09, 2016 10:42:54 AM 1 of 2
Cffw1,1.51CM4
;_... •, y
', s .t x. a
f "ACCOUNT,
f. Y, Y
" -AMOUNT
- tt,'AW.•u'
`
-gswr...°'ww...s
1
CLTD
DESCRIPTION.
QTY
: PAID
;"PAID DATE
RECEIPT #
CHECK #
METHOD
PAIDyBY_'�
BSAS SB1473 FEE
101-0000-20306
0
$1.00
$1.00
6/9/16'
R16107
BELC2016*
DEBIT
MENDOZA ELECTRIC
MFA
_
0053
Total Paid for BUILDING STANDARDS ADMINISTRATION
$1.00 $1.00
BSA:
SERVICES
101-0000-42403
0
$24.17
$24.17
6/9/16
1116107
BELC2 16*
DEBIT
MENDOZA ELECTRIC
MFA
005 3
3
-
SERVICES PC
101-0000-42600
0
$12.09
$12.09
6/9/16
R16107
BELC2016*
DEBIT
MENDOZA ELECTRIC
MFA
'
0053
Total Paid for ELECTRICAL: $36.26 $36.26
PERMIT ISSUANCE
101-0000-424040
$91.85
$91.85 ;
6/9/16
R16107
BELC2016*
DEBIT
MENDOZA ELECTRIC
MFA
0053
Total Paid for PERMIT ISSUANCE: $91.85 $91.85
TOTAL $129.11
„ INSPECTIONS
RETURNS STATUS "REMARKS
,4- REVIEW TYPE REVIEW_ ERS SENT DATE `DUE DATE t k ' _5 NOTES
` 'DATE
x x s
w
fi r ,
r
{
k 'p1
• 1 INFORMATION
Printed; Thur5daY, June 09, 2016 x0;42;54 Ann 202
' JYJII:MS.
S
.a
Qin #
Qty of La Quirata
Building 8Z Safety Division
78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building -Permit Application and Tracking Sheet
Permit #
Project Address: 51Ytf2�
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Owner's Name:
A. P. Number:
Address: J if .q
Legal Description:
City, ST, Zip: L A i
Contractor: y��
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Telephone: hone: 7 �o 0 2
P to Z 7
Address: 0- Z A i 1 E TO k Ci S�
Project Description: C'
City, ST, Zip: -Co A C.� L l
CA,
G . '
Telephone: b O-
7 i
K O K-
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C)C�
State Lie. # : 0,-1 S
City Lie. #;
Arch., Engr, Designer:
Address:
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1
City., ST, Zip:
Telephone:
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Co structi n T
n o e: Occupancy:
Y . ane Y:
P
State Lie. #
Project type �circleone • N w Add'n Alter Repair
Demo
Name of Contact Person: f? eSO,-` e,-) 9-0 Z/V
Sq. Ft.: 'O
# Stories:
# Units:
Telephone # of Contact Person: -7 tO D - L -t O `tet- -7 23'1
Estimated Value of Project: Z p O O , J -
APPLICANT: DO NOT WRITE BELOW THIS LINE
ti
Submittal
Req'd
Rec'd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted .
Item
Amount
1
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Title 24 Cales.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2" Reyiew, ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading.
IN ROUSE:-
'"! Reyiew, ready for corrections/issue .
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees,
Total Permit Fees
v1