10-0763 (ELEC)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: 10-00000763
Property Address: 45280 SEELEY DR
APN: 604-630-025- -
Application description: ELECTRICAL
Property Zoning: TOURIST COMMERCIAL
Application valuation: 2000
Ti-ty/ 4 4Q"
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 8/19/10
Owner:
EISENHOWER MEDICAL
39000 BOB HOPE DR
RANCHO MIRAGE, CA
Contractor:
Applicant: Architect or Engineer: WDL CONSTRUCTION
74075 EL PASEO,
PALM DESERT, CA
(760)674-9553
L i c. No.: 741137
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perj4aofessiona
ed under isions of Chapter 9 (commencing with
Section 7000) of Division 3 ofthe Bisde,and my License is in full force and effect.
License Class: 13 ense No.: 741137
Date: Contrr:
-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).:
(_) 1, 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.).
(_) 1, 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 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
CENTER
922
SUITE
9226C
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 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 DELOS INS Policy Number 01DKRM12007667
I certify that, in the performance of the work for which permit is issued, I shall not employ any
person in any manner s11 as to beco a subject to workers' compensation laws of California,
and agree that, if I should becom so
bject to th orkers' compensation provisions of Section
,/� 3700 of the Labor Code, I s rthwit y with those provisions.
Lii pate: iapplicant:
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 0100,000L 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 i9formation is correct. I agree to comply with all
city and county ordinances and state laws relating to building c struction, a by authorize representatives
of this county to enter upon the above -mentioned propertction p es.
date: pSignature (Applicant or Agent): r
Application Number . . . . . 10-00000763
Permit . . . . . . ELEC-MISCELLANEOUS
Additional desc . .
Permit Fee . . . . 18.75 Plan Check Fee
4.69
Issue Date . . . . Valuation . . .
. 0
Expiration Date . . 2/15/11
Qty Unit Charge Per
Extension
BASE FEE
15.00
5.00 .7500 PER ELEC DEVICE/FIXTURE 1ST 20
3.75
- ---------------------
Special Notes and Comments
-------
PODIUM ADDITION AT CONFERENCE ROOM A210
- ELECTRICAL AND DATA ONLY. 2007/2008
CALIFORNIA BUILDING CODE.
August 19, 2010 9:45:50 AM AORTEGA
-------------------------- -------------------------------
Other Fees . . . . . . . . . BLDG STDS ADMIN (SB1473)
1.00
Fee summary Charged Paid Credited
Due
---------- ---- -
Permit Fee Total 18.75 .00 .00
--
18.75
Plan Check Total 4.69 .00 .00
4.69
Other Fee Total 1.00 .00 .00
1.00
Grand Total 24.44 .00 .00
24.44
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