04-7645 (ELEC)G\ BUILDING & SAFETY DEPARTMENT
ox 150 774 (760
�N ) 7-7012
OF .NO-7o8r4,95 C°'A.LLE� �MPICO FAX (760) 777-7011
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`LA QUINTA,.- , LIFORNIA 92253 INSPECTION REQUESTS (760) 777-7153
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IP1NANCLnE BUILDING PERMIT
Application Number . . .
. . 04-00'007645. Date
12/07/04
Property Address . . . .
. 79742 HIGHWAY 111
APN:
`649-020-038- - -
Application description
ELECTRICAL
Property Zoning •. . . . .
. . REGIONAL COMMERCIAL
Application valuation . .
. . 500
Owner
------------------------
Contractor
MOOREFIELD CONSTRUCTION
------------------------
BRAY CORP, SR DBA POWER PLUS
3415 S SEPULEDA #550-
1005 N. EDWARD CT
LOS ANGELES CA 90034
ANAHEIM
CA 92806
.(714) 288-8366
-
WCC: STATE FUND
WC: 197872004
01/01/05
CSLB: 523596
01/1.3/06
----------------------------------------------------------------------------
CCC: B -C61 -C1 -D31
Perm.it . . . . ELEC-TEMPORARY POWER
Additional desc
Permit Fee
67.50 Plan Check Fee
.00
Issue.Date
Valuation . . . .
0
Qty . Unit Charge Per
Extension
BASE FEE
15.00
1.00 15.0000 EA.
ELEC TEMPORARY POWER POLE
15.00
5.00 7.5000 EA
ELEC TEMP SUB POLE
37.50
Fee summary Charged
-----------------
Paid Credited
Due
----------
Permit Fee Total 67.50
------------------------------
.00 .00
67.50
Plan Check Total
.00 .00 .00
.00
Grand Total 67.50
.00 .00
67.50
P.O. BOX 1504 • 444"
VOICE (760) 777-7012
78-495 CALLS O FAX (760) 777-7011
LA QUINTA, CALIFORNIAFOR 92253 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT /
Application Number: L�ly
Applicant:
Applicant's Mailing Address:
Date:
Architect or Engineer:
Architect or Engineer's Address.
Lic. No.:
13UILDING PERMIT DECLARATIONS
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under p It of erjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals
Code, and my Licens i i fu�rce and effect. Z 3s 9
License Class b
,qIVVVVVJ License No.9Date [Z �- / Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors' 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 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 37CO of the Labor Code, for the performance
of the work for which IN pe issued.
ve and will maintain w�Fkers o ensation insu e, as re uffreeCtLn-n t )/fpCode, for the performance of the work for which this permit is
ied.. fv1�} culcer en aC surance Carrie a li;7e C ' `'CCarrier (e licy N mberI certify that, in the performance of t work f r which this pens is employ any person in any manner so as to become subject to the workers'
compensation laws of Califomi , d agr a that, if I sho Idbe oworkers' compensation provisions of Section 3700 of the Labor Code, I shall
I comply with those pr i ons.
1 '
/ 6 � s—�
Date Applicant
WARNIN : FAI URE TO SECURE= WOR ERS' COMPENSAT*N-E01TERRAAGE 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
Lenders 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 p on at whose r and for whose benefit work is performed under or pursuant to any permit
issued as a result of this application, the owner, and a applicant ch agrees ,ands II, defend, indemnify and hold harmless the City of La Ouinta, its
officers, agents and employees for any act or omiss' n related to he ork beim performe under or following issuance of this permit.
2. Any permit issued as a result of this application be m s null and"void 'f work i not coal enced within 180 days from date of issuance of such permit, or
cessation of work for 180 days will subject permit c ncellation. /
I certify that I have read this application and state that the ab a formation i ore t. I reelo comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives of this c nt to enter up thea ova entioned property for inspection purposes.
Date l v u Signature (Applicant or Age
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