BELC2019-003178-495 CALLE TAMPICO U 1r" VOICE (760) 777-7125
LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7011
DESIGN & DEVELOPMENT DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: 3/1/2019
Permit Type/Subtype: ELECTRICAL- UTILITY (IID) RELEASE (WEB)/ Owner:
Application Number: BELC2019-0031 JAY LEE
Property Address: 78480 HIGHWAY 111 78480 HIGHWAY 111
APN: 604050042 LA QUINTA, CA 92253
Application Description: STATEWIDE / ELECTRICAL SERVICE INSPECTION
Property Zoning:
Application Valuation: P
Applicant: Contractor:
STATEWIDE SERVICES INC DBA STATE WIDE PL STATEWIDE SERVICES INC DBA STATE WIDE PL
73700 DINAH SHORE STE 405 MAR 0 12019 73700 DINAH SHORE STE 405
SUITE 405 SUITE 405
PALM DESERT, CA 92211 CITY OF LAQUINTA PALM DESERT, CA 92211
DESIGN & DEVELOPMENT DEPARTMENT L160c. No9 -54347
LICENSED CONTRACTOR'S DECLARATION WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury that I am livens nder pJProfessio
ter I hereby affirm under penalty of perjury one of the following declarations:
9 (commencing with Section 70001 of Division 3 of th Business de, I have and will maintain a certificate of consent to self -insure for workers'
and my License is in full force and effect. compensation, as provided for by Section 3700 of the Labor Code, for the performance
License Class: C3G, C3, C10. A, B License No.: 9 of the work 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: BEN MARK INSURANCE COMPANY Policy Number: aTSS115156
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 thew kers'
compensation laws of California, and agree that, if I should become subject he
workers' compensation provisions of Section 3700 of hhe_ab0r .4d% I a F thwlth
comply with those provisions.
Dated L _. Contractor
OWNER -BUILDER DECLAT[ON
I hereby affirm under penalty of perjury that I am exem-Pffrom 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).:
(_) 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 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. Q.
Lender's
Lender's Address:
Date: l_N _ Applicant:
WARNING: FAILURE TO SECURE WORKERS' COMPS SATION ERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL P S 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 a
I agree to comply with all city and county ordinances and state laws relating to t
construction, and hereby authorize representatives of this city the
above -mentioned property for inspection purposes._
Date'`' .- l \ Signature (Applicant or Agent);'
Date: 3/1/2019
Application Number: BELC2019-0031
Property Address: 78480 HIGHWAY 111
APN: 604050042
Application Description: STATEWIDE / ELECTRICAL SERVICE INSPECTION
Property Zoning:
Application Valuation:
Applicant:
STATEWIDE SERVICES INC DBA STATE WIDE PL
73700 DINAH SHORE STE 405
SUITE 405
PALM DESERT, CA 92211
Detail: ELECTRIC SERVICE RELEASE
Owner:
JAY LEE
78480 HIGHWAY 111
LA QUINTA, CA 92253
Contractor:
STATEWIDE SERVICES INC DBA STATE WIDE PL
73700 DINAH SHORE STE 405
SUITE 405
PALM DESERT, CA 92211
(760)699-5434
Llc. No:: 936147
DESCRIPTION
ACCOUNT I CITY I AMOUNT
ELECTRICAL- UTILITY RELEASE 101-0000-42400 0 $80.05
Total Paid for ELECTRICAL - UTILITY RELEASE: $80.05
DESCRIPTION
ACCOUNT
QTY
AMOUNT
TECHNOLOGY ENHANCEMENT FEE
502-0000-43611
0
$5.00
Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00
- D,r LRr -
Project Address:
APN #:
Applicant Name: ` ke U
Address: C� 1
City, ST, Zip:
Telephone: _C Ll
Email: �z. _ . -r, ..! ► ` ]
Contractor Name-
Address -
City, St, Zip
Telephone:
Email:
State Lie: City Bus Lie:
Arch/Eng Name:
Address:
City, St, Zip
Telephone:
Email:
State Lie:
City Bus Lie:
Property Owner's Name:
Address:
City, ST, Zip
Telephone: '
a
22 I l
PERMIT # XLC?,O(l so
PLAN LOCATION:
Project Description: Pool, Remodel, Add't, Elect, Plumb, Mech
VA�,
Valuation of Project S
New SFD Construction:
Conditioned Space
Garage
Patio/Porch
Fire Sprinklers
Construction Type:
Grading:
Bedrooms: f Stories:
SF
SF
SF
SF
Occupancy:
# Units:
New Commercial / Tenant Improvements:
Total Building SF
Construction Type: Occupancy:
78495 CALLE TAMPICO
LA QU I NTA, CA 92253
760-777-7000