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BLEC2017-0091LICENSED CONTRACTOR'S DECLARATION 1 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: B License No.: 346196 Q Date: �� �� % ,Co- ntractor �xr 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).: (_j 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.). ( 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 Na Lender's 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 t�he °rk 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: STATE COMPENSATION INSURANCE FUND Policy Number: 9074584 1 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. Date? l l �� .Applic 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 Drooerty for insoection ourooses. [1J O aw VOICE (760) 777-7125 `78495 CALLE TAMPICO D . FAX (760) 777-7011 LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT INSPECTIONS (760) 777-7153 BUILDING PERMIT Date: 10/11/2017 Permit Type/Subtype: ELECTRICAL/ Owner: Application Number: BELC2017-0091 > JAMES KELLY Property Address: 78471 TALKING ROCK TURN 53930 DEL GATO APN: 770300047 LA QUINTA, CA 0 Application Description: KELLY/ TEMP POWER POLE Property Zoning: Application Valuation: $500.00 D Applicant: Contractor: KELLY DOMER PARTNERS INC DBA KELLY PACIF c� OCT 12 2JCITYOFLAQUINTA KELLY DOMER PARTNERS INC DBA KELLY PACIF 1554 LINCOLN AVE 1554 LINCOLN AVE SAN RAFAEL, CA 94901 SAN RAFAEL, CA 94901 COMMUNITY DEVELOPMENT DEPARTMENT (415)464-0900 . Llc. No.: 346196 LICENSED CONTRACTOR'S DECLARATION 1 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: B License No.: 346196 Q Date: �� �� % ,Co- ntractor �xr 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).: (_j 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.). ( 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 Na Lender's 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 t�he °rk 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: STATE COMPENSATION INSURANCE FUND Policy Number: 9074584 1 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. Date? l l �� .Applic 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 Drooerty for insoection ourooses. [1J Date: 10/11/2017 Application Number: BELC2017-0091 Owner: Property Address: 78471 TALKING ROCK TURN JAMES KELLY APN: 770300047 53930 DEL GATO Application Description: KELLY / TEMP POWER POLE LA QUINTA, CA 0 Property Zoning: Application Valuation: $500.00 Applicant: Contractor: KELLY DOMER PARTNERS INC DBA KELLY PACIF KELLY DOMER PARTNERS INC DBA KELLY PACIF 1554 LINCOLN AVE 1554 LINCOLN AVE SAN RAFAEL, CA 94901, SAN RAFAEL, CA 94901 (415)464-0900 Llc. No.: 346196 Detail: TEMPORARY POWER POLE (100 AMP). PER 2016 ELECTRICAL CODE. r FINANCIAL INFORMATION DESCRIPTION ACCOUNT QTY AMOUNT BSAS S61473 FEE 101-0000-20306 0 $1.00 . Total Paid for'BUILDING STANDARDS ADMINISTRATION.BSA: $1.00 DESCRIPTION ACCOUNT QTY AMOUNT TEMP POWER SERVICE 101-0000-42403 0 $26.01 DESCRIPTION ACCOUNT I QTY AMOUNT TEMP POWER SERVICE PC 101-0000-42600 0 $18.20 Total Paid for ELECTRICAL: $44.21 DESCRIPTION ACCOUNT. QTY AMOUNT PERMIT ISSUANCE 101-0000-42404 0 $98.83 Total Paid for PERMIT ISSUANCE: $98.83 DESCRIPTION ACCOUNT QTY AMOUNT RECORDS MANAGEMENT FEE 101-0000-42416 . 0 $10.00 Total Paid for RECORDS MANAGEMENT FEE: $10.00 DESCRIPTION ACCOUNT , QTY AMOUNT TECHNOLOGY ENHANCEMENT FEE 502-0000-43611 0 $5.00 Total Paid for TECHNOLOGY ENHANCEMENT FEE: . $5.00 6 E Bin# City of La Quinta Building & Safety Division 78-495 Calle Tampico La Quinta, CA 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet Permit# Proje 7. YJ f l Loo b� K¢K Owner's Na e:�M'yaS r A=.¢ A.P. Number –7 - a 000 Sd Address: 7 9 Legal Description: City, ST, ZipZ Contractor: L _ caKs j— ( Telephoney.- Address: Project Description: City, ST, Zip: Telephon !60''t0 StateLic..#: Lity'Lic#: G p Arch, Eng-r., Designer: Address: City, ST, Zip: Telephone: Construction Type: aN" D Proj. Type New Add'n Occupancy: Altc: Repair Demo State Lic. #: Name of Contact: C C (A J C_ SgFt: #Stories # Units: Telephone of Contact:7� d c7� C) :(��L Estimated Value of Project: G Q APPLICANT: DO NOT WRITE BELOW THIS LINE # Submittal Req'd Rec'd TRACKING PERMIT FEES Plan Sets Plan Check Submitted Item Amount Structural Calcs Reviewed, ready for corrections Plan Check Deposit: Truss Calcs Called Contact Person Plan Check Balance: Title 24 Calcs Plans Picked Up Construction: Flood Plain Plan . Plans Resubmitted Mechanical: Grading'Plan 2nd Rev, Ready for corrections / Electrical: Subcontractor List Called Contact Person Plumbi-3g: Grant Deed Plans Picked Up S.M.I. HOA Approval Plans Resubmitted Grading IN-HOUSE 3rd Rev, Ready for corrections / Developer Impact Fee Planning Approval Called Contact.Person ' A.I.P.P Pub. Wks. Apps Date of permit issue School Fees Total P.rmit Fees �1 � . e � ,� ..— h ��I 1 �` � . ��� � �� J� �:- ., 1 �. �'�.. -� '��= - - .N S • � � i tm ^� �• N � \• �� ''� f �' � r f '�° ® � f � _ �'. ���Z•SvS t.. J � ��� � ..