12-1077 BPP.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
T4ht 4 l&Qgr«tw
Application Number:
12-00001077
Property Address:
80049 AVENUE 52
APN:
772-410-997-CC -32070 -
Application description:
STRUCTURES OTHER THAN BUILDINGS
Property Zoning:
MEDIUM HIGH DENSITY RES
Application valuation:
15000
Applicant: Architect or Engineer:
.�U
V
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 Class: A C7 License No.:. 597074
Date: �v50ntractor-'itZiNDf1
OWNER -BUILDER DECLARATION
I hereby affirm under penalty Of perjury that 1 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 roWifes a permit to
canatruct, alter, Improve, demolish, Or repair any structure, prior to its Issuance, also requires the appFicam for the
permit to Iiie 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
[fiat he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7037.5 by
any applicam for a permit subjects the applicant to a civil panatty of rat more than Five hundred dollars IS600).:
} 1. as owner of the property. or my employees:with wages as their sole compensation, will do the work, and
the srructum is not intended or Offered for sale iSec. 7044, Business and Professions Code: The
Contractors' State License Law does not apply to on owner of property who builds Or improves thereon.
artd 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 oWnar-bulkier will have the burden of proving that he or she did not build or
Improve for the purpose of sale.].
{ —1 I, as owner at the Prop", am exciu9ively contracting with licensed contractors to construct the proiuct (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 far the protects with a coFinactor(sl licensed
pursr7am to the Contractors' State License Law.).
} I am exempt under Sac. . 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: —
Owner:
CITY OF LA QUINTA
78495 CALLE TAMPICO
LA QUINTA, CA 92253
Contractor:
PACIFIC WEST SPACE
900 W_ GLADSTONE ST
SAN DIMAS, CA 91773
(909)772-4277
Lic. No.: 597074
VOICE (760) 777-7012
FAX (760) 777-70.11
INSPECTIONS (760) 777-7153
Date: 1/23/13
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
_ I have and will maintain a certitTuate 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.
_ 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 workerscompensation
insurance canner and policy number are:
Carrier OLD REPUBLIC Pollcy Number A1CW96851303
I certify thot, in the performance of the work for which this permit is issued. I .shell net emptey any
person In any manner so as:to become subject to the workers' compensation laws of California.
and agree that, it I should become sublets to the workers' compensation provisions of Section
3700 of the Labor Code, I shall forthwith comply with those provisiom.
DateGl 8 I!VApplicant:
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 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 mid held harmless the City
of LS Quinta, its officers, agents and employees for any act or omission reJawd 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 county to enter upon the above -mentioned property for inspection purposes.
Date'm -zb I V Signature {Appllcant or Agentl:'�.+��
LQPERMIT
12-00001077
Application Number - . .
BUILDING PER.I4IT
10 5.3 0
Permit plan Check Fee
15000
00 tion
Additional desc 162.Valua
Permit Pee _ 3 7'2�I1
Issue Date
Extension
45.00
E�cp,ration Date
117.00
Per BASE FEE
Qtj� Unit Charge 001-25,000 ----------------
g_0000_TH0U__BLD, 2,001---------_---
13.00
------------ -----` ELFC-MISCELLANEOUS
11.31
Permit Plan Check Fee -
Additional desc 45.25 Valuation
0
Permit Fee
Issue Date 7/22/13
Extension
15-00
E.piration Date -
.75
Per
Qty Unit Charge BASE FEE LIGHT
E'EC POCSVC
18.50
7500 K=600V/e-=200A
1.00 lg_5000 EA ELEC MIS - ----------------
ELE------
-11_00-
1.00 11.0000 EA --------
-
1-p0-----------
_---`------7 Notes and Comments RA LIGHT`
POLE TOP ANTEN' (ADJ - To
I3aT
36ft MAX' O W ALONG AVENUE PER 2010
R• DESIGN
POLE IN
ENGINEERED
ROUNDp$OL7T} • ENG114BER- ADR
----
S ----------------
CODES AND �'IT� ___________________
Mc0UN IN C57075------------ - pDMIN (SB1473)
1.00
507.50
- - - - - - - - - - - - HOURLSy pLAN CHECK
_ CpM
(SMI)
3.15
Other Fees STRONG MOTION
Credited
Due
Paid - ----------
Charged -_____- -------`
207.25
Fee su�a� ------------ --- .00 .00
--- 207.25
116.61
511.65
.00 .00
-permit Fee Total 116.61 00 .00
Check Total 511.65
835.51
Plan .00
Other Fee Total 835.51
Grand Total
LQPERMIT