BDEM2017-0001LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that• 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 Cl ss: C21. A License No.: 473328
'L6µC�(Tto-Z)
Date: 2! Contractor:
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that 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.).
(_) I am exempt under Sec. . B.&P.C. for this reason
Date:
Owner:
CONSTRUCTION LENDING AGENCY
1 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:
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'
co&Pa,,,n,asprovifor by Section 3700of the Labor Code, for the performance
ofor which this permit is issued.
have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the perfornance of the work for which this permit
is issued. My workers' compensation insurance carrier and polity number are:
Carrier: ACE AMERICAN INSURANCE COMPANY Policy Number: RWCC48815881
I certify that in the performance of fie 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 thac, if I should become subject to the
workers' compensation provisions of Section 3'0011hLabor Code,Lall thwith
comply with those rovisions.
Date: Applicant:
WARNING: FAILURE TO SECURE WORKERS' COIdPENSATION COVERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINI4L 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 owne and the applicant, each agrees to, and
shall defend, indemnify and hold harmless the =ity of La Quinta, its officers, agents, and
employees for any act or omission related to tFe 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 6suance 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 representa-.ives of this city enter upo the
above -men 'onproperty for inspection purposes.
Date: Z v ( Signature (Applicant :)r Agent):
VOICE (760).777-7125
78-495 CALLE TAMPICO
D
FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253
DESIGN & DEVELOPMENT DEPARTMENT
INSPECTIONS (760) 777-7153
BUILDING PERMIT
/
Date: 2/21/2017
Application Number:
BIDE M2017-0001
Owner:
Property Address:
46080 JEFFERSON ST ST
EJ LA QUINTA, LLC
APN:
600070012
42600 MIRAGE RD
Application Description:
CONTOUR DERMATOLOGY/
EXISTING BUILDING DEMOLITION
RANCHO MIRAGE CA 92270
Property Zoning:
Application Valuation:
$85,000.00
�¢
0 o ti
N �
Applicant:
Contractor:
O�W
Cy L o
DEMO UNLIMITED INC
DEMO UNLIMITED INC
LL
0
81750 AVENUE 50
81750 AVENUE 5C
U
INDIO, CA 92201
INDIO, CA 92301
o
(760)775-5884
v
LIC. No.: 473328
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that• 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 Cl ss: C21. A License No.: 473328
'L6µC�(Tto-Z)
Date: 2! Contractor:
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that 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.).
(_) I am exempt under Sec. . B.&P.C. for this reason
Date:
Owner:
CONSTRUCTION LENDING AGENCY
1 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:
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'
co&Pa,,,n,asprovifor by Section 3700of the Labor Code, for the performance
ofor which this permit is issued.
have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the perfornance of the work for which this permit
is issued. My workers' compensation insurance carrier and polity number are:
Carrier: ACE AMERICAN INSURANCE COMPANY Policy Number: RWCC48815881
I certify that in the performance of fie 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 thac, if I should become subject to the
workers' compensation provisions of Section 3'0011hLabor Code,Lall thwith
comply with those rovisions.
Date: Applicant:
WARNING: FAILURE TO SECURE WORKERS' COIdPENSATION COVERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINI4L 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 owne and the applicant, each agrees to, and
shall defend, indemnify and hold harmless the =ity of La Quinta, its officers, agents, and
employees for any act or omission related to tFe 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 6suance 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 representa-.ives of this city enter upo the
above -men 'onproperty for inspection purposes.
Date: Z v ( Signature (Applicant :)r Agent):
(F
Application Number:
BDEM2017-0001
Owner:
Property Address:
46080 JEFFERSON ST ST
EJ LA QUINTA, LLC
APN:
600070012
42600 MIRAGE RC
Application Description:
CONTOUR DERMATOLOGY/ EXISTING BUILDING DEMOLITION
RANCHO MIRAGE, CA 92270
Property Zoning:
Application Valuation:
$85,000.00
Applicant: Contractor:
DEMO UNLIMITED INC DEMO UNLIMITEC INC
81750 AVENUE 50 81750 AVENUE 50
INDIO, CA 92201 INDIO, CA 92201
Date: 2/21/2017
(760)775-5884
Llc. No.: 473328
--=------------------------------------------------------------------------------------------
Detail: DEMOLITION OF ENTIRE EXISTING STRUCTURE INCLUDING BASEMENT [APPROXIMATELY 2,500SF W/ 1,000SF BASEMENT] THIS PERMIT DOES NOT
INCLUDE SITE WORK OR GRADING. 2016 CALIFORNIA BUILDING CODES.
Total Paid for'DEMOLI-ION: $111.68
DESCRIPTION'
FOR
ACCOUNTQTY
AMOUNT
CASH OVER
101-0000-42300
0
$5.99
Total Paid for CASH OVER:
$5.99
DESCRIPTION
ACCOUNT
QTY
AMOUNT
DEMOLITION, FULL
101-0000,42404
0
$24.66
DESCRIPTION
ACCOUNT
D.TY
AMOUNT
DEMOLITION, FULL PC
101-0000-42600
0
$87.02
Total Paid for'DEMOLI-ION: $111.68
r