10-0748 (ELEC)P.O. BOX 1504 Y ��� VOICE (760) 777-7012
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: 8 / 18 / 10
Application Number: 10-00000748 Owner:
Property Address: 45280 SEELEY DR EISENHOWER MEDICAL CENTER
APN: 604-630-025- - 39000 BOB HOPE DR
Application description: ELECTRICAL RANCHO MIRAGE, CA 92270
Property Zoning: TOURIST COMMERCIAL
Application valuation: 1000 �-11tA:UtG242010
�"'��
Contractor:
Applicant: Architect or Engineer: - WDL CONSTRUCTION
74075 EL PASEO, SUITE - i
PALM DESERT, CA 92260 t
(760)674 9553 C1TY0F1AfdUi l,_ 1
t9� Lic. No : 741137 FINA'I EDEFT.
LICENSED CONTRACTOR'S DECLARATION
hereby affirm under penalty of perjury that I am.J!99ddpd under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business a of io s Cade, and my License is in full force and effect.
LicenseCllaen B License No.: 741137
_( Date: elel ip Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty o erjury 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 (S500).:
(_ 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 orimprovement 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.).
'1 1 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).) licensed
pursuant to the Contractors' State License Law.).
( ) I am exempt under Sec. , B.&P.C. for this reason
Data
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.I. _
Lender's Name:
Lender's Address:
LQMRMIT
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.
I have and will maintain workerscompensation insurance, as required by Section 3700 of the Labor
Code, for the performance of the work for which this permit is issuetl. My workers' compensation
insurance carrier and policy number are:
Carrier DELOS INS Policy Number. 01DKRM12007667
certify that in the performance of the rk for whi this permit is issued, shall not employ any
person in any manner so as to be subject he or
is
laws of California,
and agree that, if should beco object we
compensation provisions of Section
3700 of the Labor Code, re i ply with those provisions
gate: & Applicant:
WARNING: FAILURE TO SECUfl ORKERS' 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 and hold harmless the City
of La Quints, 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 at
I agree to comply with all
city and county ordinances and state laws relating to building con action, a ereby authorize representatives
of this county
to enter upon the above -mention
property f pection poses.
)late: �G / �S Signature (Applicant or Agand:
Application Number . . . . . 10-0.0000748
Permit . . ELEC-MISCELLANEOUS
Additional desc . . -
Permit Fee . . . . 15.75 Plan Check Fee
3.94
Issue Date . . Valuation . . .
.
0
Expiration Date . . 2/14/11
Qty Unit. Charge Per
Extension
BASE FEE
15.00
1.00 .7500 PER ELEC DEVICE/FIXTURE 1ST 20
.75
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Special Notes and Comments
ADD COUNTER/WORKSTATION LIGHT AT 1ST
FLOOR TI WEST [ROOM C1301 2007/2008
CALIFORNIA BUILDING CODES.
August 18, 2010 2:41:22 PM AORTEGA
----------------------------------------------------------------------------
Other Fees . . .- . . . . . . BLDG STDS ADMIN (SB1473)
1.00
Fee summary Charged Paid Credited
----------------- ----------
Due
---------- ---------- ----------
Permit Fee Total 15.75 .00 .00
15.75
Plan Check Total 3.94 .00 .00
3.94
Other Fee Total 1.00 .00 .00
1.00
Grand Total 20.69 .00 .00
20.69
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