BDEM2017-000478-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
. 4
DESIGN & DEVELOPMENT DEPARTMENT
BUILDING PERMIT
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Application Number: BDEM2017-0004 Owner:
Property Address: 78437 HIGHWAY 111 HARSCH INV REALTY
APN: 604050059 1121 SALMON ST 4TH FL
Application Description: HARSCH / DEMOLITION OF EXISTING TENANT IMPROVEMENTS PORTLAND, OR 92253 '
Property Zoning:
Application Valuation: $20,000.00
... ` ....
PUD
Applicant: Contractor:
HARSCH INV REALTY JUN 2 8 2017 DEACON CONSTRUCTION LLC
1121 SALMON ST 4TH FL 7745 GREENBACK LANE
PORTLAND, OR 92253 CITY OF LA (JINTA CITRUS HEIGHTS, CA 95610
DESIGN AND DEVELOPMENT DEPARTMENT (916)969-0900
Lic. No.: 1022330
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: A. B License No.: 1022330
'ate%., q W ontractor:
6 LTt 2a r7�~
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, 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, 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.).
(__j 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 Address:
Date: 6/28/2017
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.
fmI 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: ZURICH AMERICAN INSURANCE COMPANY Policy.Number:
WC350459116
_ 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. % /%
Datfbr/25%1, 2d Annl f // 4,- 2-4
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.
Da��T,2 $l2dl /�ienatuie�(Aoolic Ae'enY1 // / /i'�►/ ��
I
Date: 6/28/2017
Application. Number: BDEM2017-0004
Owner:
Property Address: 78437 HIGHWAY 111
HARSCH INV REALTY
APN: 604050059
1121 SALMON ST 4TH FL
Application Description: HARSCH / DEMOLITION OF EXISTING TENANT IMPROVEMENTS
PORTLAND, OR 92253
Property Zoning:
Application Valuation: $20,000.00
Applicant:
Contractor:
HARSCH INV REALTY
DEACON CONSTRUCTION LLC
1121 SALMON ST 4TH FL
7745 GREENBACK LANE
PORTLAND, OR 92253
CITRUS HEIGHTS, CA 95610
(916)969-0900
----------------------------
Llc. No.: 1022330
-----------------------------------------------------------------
Detail: DEMOLITION OF EXISTING PARTITION WALLS, FLOOR FINISHES, AND PLUMBING AND ELECTRICAL INSTALLATIONS. ITEMS TO REMAIN ARE AS
FOLLOWS: SUBPANEL,"BATHROOMS, CEILING AND LIGHTING AND HVAC SYSTEM AND DISTRIBUTION. SEPARATE PERMIT IS REQUIRED FOR FUTURE
IMPROVEMENTS AND BUILDING OCCUPANCY. 2016 CALIFORNIA BUILDING CODES.
I
FINANCIAL
'DESCRIPTION
INFORMATION
ACCOUNT
QTY
AMOUNT
Credit Card Fee
101-0000-43505
0
$2.11
Total Paid for Credit Card Fee:
$2.11
DESCRIPTION
ACCOUNT
QTY
AMOUNT
DEMOLITION, FULL
101-0000-42404
0
$25.84
DESCRIPTION
ACCOUNT
QTY
AMOUNT
DEMOLITION, FULL PC
101-0000-42600
0
$91.20
Total Paid for DEMOLITION: $117.04
u