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12-0145 (ELEC)„, a P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Z, -_”, Application Number: 4-12-00000145 ' '%- o Property Address: 53866 ROSS AVE APN: r 767-200-998-41 -330761- Application description: ELECTRICAL Property Zoning: LOW DENSITY RESIDENTIAL Application valuation: 800 - Ta�v - 4 etP Q" Applicant: Architect or Engineer: LICENSED CONTRACTOR'S DECLARATION BUILDING & SAFETY DEPARTMENT BUILDING PERMIT 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 Professionals Code, and my License is in full force and effect. License Clas : B License No.: 848057 J)ete: � omractor: / OWNER-BUILDE!DECTION 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, 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.). - 1 _ I 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: LQPERMIT Owner: ALAN AUSTIN 53866 ROSS AVENUE MORENO VALLEY, CA 92553 Contractor: BRADSHAW CONSTRUCTION INC 46248 ROUDEL LN LA QUINTA, CA 92253 (760)347-4246 Lic. No.: 848057 VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 2/17/12 IFEB 17 2011 LI CITY OF LA QUINTA ----------------------------------------------- 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. 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 STATE FUND Policy Number 71950202311 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 3 00 of th Labor Code, I shall forthw' i Mply with tho provisions. ate' pplicant: WARNING: AI LURE TO SECURE WORKERS' COMPENSATION COVERA E IS UNLAWFUL, AND SHALL SUBJECT 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 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 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 auth ize representatives of th' o ty t enter upo a above-mentioned property for inspectioO.Aurpos s. Dat ignature (Applicant or Agent,: CV\` Application Number . . . . . 12-00000145 Permit . . . ELEC-TEMPORARY POWER Additional desc . Permit Fee 30.00 Plan Check Fee .00 Issue Date . . . . Valuation . . . . 0 Expiration Date 8/15/12, Qty Unit Charge Per Extension BASE FEE 15.00 1.00 15.0000 EA ELEC TEMPORARY POWER POLE 15.00 ---------------------------------------------------------------------------- Special Notes and Comments TEMP POWER POLE FOR CONSTRUCTION. 2010 CODES. ---------------------------------------------------------------------------- Other Fees . . . . . . . . . .BLDG STDS ADMIN (SB1473) 1.00 Fee summary Charged ------- - -- ---------- Paid Credited ---------- ---------- Due ----------------- Permit .Fee Total 30.00 .00 .00 30:00 Plan Check Total .00 .00 .00 .00 Other Fee Total 1.00 .00 .00 1.00 Grand Total 31.00 ..00 .00 31.00 LQPERMIT AICC)R�® v CERTIFICATE OF LIABILITY INSURANCE DATE (MMI0r1y2 Y) 2/16/2oi2 ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS' CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Druml Group, Inc. 1135 Farragut Blvd Foster City CA 94404 CONTACT David Mahler NAME: PHONE (BOO) 949-6241 FAC o: (650)341-8352 E-MAIL .dmahler@drumlgroup.com INSURERS AFFORDING COVERAGE NAIC # INSURERA:Interstate Fire & Casualty 2829 INSURED Bradshaw Construction, Inc. 46-248 Roudel Lane La Quinta CA 92253 INSURERB:We3CO Insurance Company 5011 INSURERC:State Comp. Insurance Fund 35076 INSURERD:Travelers Property Casualty 5674 INSURER E: INSURER F: rnvFVAn=Q (^FRTIFIr_ATF NIIMRFR•CL122300685 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER EFF MMIDD/YYYY MPOLICY PMLI Y EX IDD/YYYY LIMITS AUTHORIZED REPRESENTATIVE GENERAL LIABILITY La Quinta, CA 92253 David Mahler/DKK EACH OCCURRENCE $ 1,000,000 MERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 MED EXP (Any one person) $ ACLAIMS-MADE ❑XOCCUR GL -1002818 /25/2011 /25/2012 PERSONAL & ADV INJURY $ 1,000,000 NGEILOAGGREGATE GENERAL AGGREGATE $ 2,000,000 LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 $ POLICY I X I PRO LOC AUTOMOBILE LIABILITY Ea acclideDISINGLELIMIT 11000,000 BODILY INJURY (Per person) $ B ANY AUTO ALL OWNED X SCHEDULED AUTOS NON -OWNED X HIRED AUTOS AUTOS P1028167 00 /26/2011 /26/2012 BODILY INJURY (Per accident) $ PROPERTYDAMAGE $ PERT accident $X Uninsured motorist combined $ 1,000,000 UMBRELLA LIABOCCUR HCLAIMS-MADE EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR DED I I RETENTION $ $ C WORKERS COMPENSATIONX C STATU- OTH- Y LIMIT 9, AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE Y OFFICER/MEMBER EXCLUDED? (Mandatory In NH) N / A 1950202311 /1/2012 /1/2013 E.L. EACl- ACCIDENT $ 11000,000 ELL - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below D COMMERCIAL PROPERTY T-660-6775P35A-TIL-11 /10/2011 /10/2012 LEASED/P.ENTEDEQUIP $50,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) [Re: 53659 Ross Avenue, Lot 36A, La Quinta, CA] CFRTIFICATF HOI nFR CANCELLATION ACORD 25 (2010/05) INS025 (201005).01 ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of La Quinta 78-495 Calle Tampico AUTHORIZED REPRESENTATIVE La Quinta, CA 92253 David Mahler/DKK ACORD 25 (2010/05) INS025 (201005).01 ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD B,n # �dty. �f La Quinta Building 8L 5arety Division P.O. Box 1504,-78-495 Calle Tampico ,. La.Quinta, CA 92253 -:(760) 777-7012 Building Permit Application and Tracking Sheet Permit # G Project Address: .53 606 6 Q 5 S Owner's Name:. f"'1 U A. P. Number. Address: g �6 (0. Qss L) t - Legal Description: City, ST, Zip: t a 5 3 Telephone: >• >� :���' y:;` iyre� 1� Contractor. �� ► i AW 0 pi S (U C Q VN Address: . �j U dC A Prc jest Description: City, ST, Zip: �.,c .,� r n 1I ^r Telephone:'' State Lic. #: g 0 S City Lie'. # Arch., Engr., Designer: S TE-? ( t4 es I Address: 1 City, ST, Zip: _R41 II A �t�. e r+ Ek. 9 a a loo Telephone: 7t�� -&� L� ' State Lic. #:� "�" _ Name of Contact Person �� �X.IIt°� e Construction Type:. .,Res,. Occupancy: Project type (circle one): dp Add'n Alter Repair Demo Sq. Ft : �' a� # Stories: # Units: Telephone # of Contact Person: Fj Q -aq 6 — 'y11 Estimated Value of Projed# APPLICANT: DO NOT WRITE BELOW THIS UNE # Submittal Req'd Recd TRACMG PERMIT FEES Plan Sets Plan Check submitted Its Amount Structural Calm Reviewed, ready for corrections Plan Check Deposit. . Truss Calcs. Called Contact Person Plan Check Balance Title 24 Calci. Pians picked up Construction Flood plain plan Plans resubmitted • . Mecharilcal Grading plan 2'" Review, 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:- '^' Review; ready for eorrectionslissue Developer Impact Fee Planning Approval. Called Contact Person A I.P.P. Pub. Wks. Appr Date of permit issue School Fees Total Permit Fees ' r .