08-0616 (ELEC)1
P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253.
BUI_LDING, & SAFETY DEPARTMENT 11 �
BUILDING PERMIT
Application Number: 08-000,00616 Owner:
Property Address: 47800 DUNE PALMS RD SKYLINE PACIFIC PROP.
APN: 600-020-012- - - C/O RICK RONALD
Application description: ELECTRICAL 558 SACRAMENTO ST
Property Zoning: COMMERCIAL PARK SAN FRANCISCO, CA
Application valuation: 500
Applicant: Architect or Engineer:
-�a
OU
11
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LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perj*ury_!DAt I am licensed under provisions of Chapter,9 (commencing with
Section 70001 of Division 3 of the B ess Professionals - e, and my License: is, in full force ,And effect.
License Cla C10 C20 C3 ice .No.: 482623
Dater Contracto
OWNER -BUILDS ECLARATION
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, Businessand`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 Caw (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 morethan.five hundred dollars (95001::.
(_ 1 I, as. owner of the property, or my employees with wages as their sole compensation, will do thwwork, and
the structure is not intended,or offered for sale (Sec. 7044, Business and Professions Coder The
Contractors' S_tate,License Law doe_ snot apply to an owner of property who buildsor improves thereon,
and who does the work himself or herself -through his or her own employees,, provided that:.the
improvements are:not;intended oroffered 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.).
1 _) 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 Lew does not applyto 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 Lew.).
( ) I am exempt under Sec. , B.&P.C. for this reason
Date: _ _ Owner: _
CONSTRUCTION LENDING AGENCY
I herebyzffirm under penalty ofperjury that there isa 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:
I.QFMMFF
Contractor'
BRUDVIK, INC.
600 EUGENE ROAD
PALM SPRINGS, CA
(760)320-4429
Lie. No.: 482623
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 4/15/08
------------------------------------------F- - --- --
WORKER'S COMPENSATION' DECLARATION
Ihereby 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 INS CO OF ,WEST Policy Number WSD215878103
I certify that, in the performance of the work for which this permit is issued, I shall not employ any
person inanymanner swas.to.become subject tothe workers" compensation laws of California,
and agree:that, ifl.sh become subject to the, workers' compensation provisions of Section
3700. of the Labor e, shall forth-- ply with those provisions.
Date Applicant/
or
WARNING: FAILURE TO..SECURE'WORKERS' COMPENSAT ON COVERAGE IS UNLAWFUL, AND., SHALL
:SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINESUP TO ONE HUNDRED THOUSAND
DOLLARS (5100,000). 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 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 ismade, each person at whose request and for
whose.beriefit work is performed under or pursuant to any permit issued as a result of this application,
theowner, and the applicant, eachagrees to, and shall defend, indemnify and hold harmless the City
of La Quinta„its officers, agents and employees for any act or omission related .tothe work being
performed under or following issuanceofthis permit.
2. Any permitissued as a result of this application becomes null and void.if work is notcommenced
within 180 days from date of issuance at such permit, or cessation of work for 180 days willsubject
permit to cancellation.
I certify that] have read this application and 'state that the.above information iscorrect. I agree to comply with all
city and county ordinances and state laws -relating to bui "rg construction nd'hereby authorize representatives
of this county to nt ct
upon the above-mentioned pr rty or inspei mpu ses.
Date: 14�1_ ignature (Applicant or Ag
Application Number . . . . . 08-00000616
Permit . .
. ELEC-MISCELLANEOUS
Additional desc .
Permit Fee . . .
. 30.00
Plan Check Fee
.00
Issue Date
Valuation . . .
. 0
Expiration Date
10/12/08
Qty Unit Charge
Per
Extension
BASE
FEE
15.00
1.00 15.0000
EA ELEC
TEMPORARY POWER POLE
15.00
--------------------------------------------
Special Notes and
Comments
------------------------------------
TEMPORARY POWER TO
JOB SITE OFFICE
TRAILER.
Fee summary
Charged
Paid Credited
Due
Permit Fee Total
--
3.0.,00
------ ---------- ----------
.00 .00
30.00
Plan Check Total
.00
.00 .00
:0:0
Grand Total
30.00
.00 .00
30.00
LQrEMff
City' ST, "P:
Telephone: Constriction Type: occupmcr
State Lie,. #: Project type (circle.one)• Add'n 'Alter Repair Demo
Name of ContactPerson: r^
Sq. Ft: IUnits
Telephone # of Contac Person:
— — Estimated Value.of Project
APPUCANT:. DO NOT WRR'E BELOW THIS UNE; ..
# Submittal Req'd Ree.•d TRACKING . PERMUrr FEES
PlaaSeb Plan Check submitted Item Amount
stmct"cdml
Reviewed; ready for correctionsW'C:"cd
eposit
Trials Cales.
Called Coated Person
alance
Energy Cdcs.
Plans iSicked up
on
Construction
Flood.plein plan.
Plans resubmitted
Grading pla4
Y' Review, ready for correcdooaflssae
Sabcoutactor List
Called-ContactPerson
Plumbing
Grant -Deed
Plans• pickedve
SALL
DLO.A, Approval
Plans resubmitted
Grading
IN HOUSE.-
''' Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
Pub. Wks. Appr
Date of permit issue
School Fees
CITY OF LA QUINTA
BUILDING & SAFETY DEPT
APPROVED
FOR CONSTRUCTION
DATF-- �151V�5 By - L_
SAM'S CLUB PLANTER AREA
47-795 DUNE PALMS ROAD
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BRUDVIK, INC. OFFICE TRAILER
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