HomeMy WebLinkAboutELEC18-0019City of Palm Desert
Building Safety Department
PERMIT NUMBER:
ISSUED DATE:
and
73510 Fred Waring Drive
ELEC18-0019
312812018 12:00:00 AM
Palm Desert, CA 92260
Appl. Date: 3/28/2018
Permit Type: ELECTRICAL
Permit TEMPORARY POWER
Subtype: POLE
Job Valuation: $1,000.00
Appr. Date: 312812018
Exp, Date: 9/24/2018
Project Address: 23 AVENIDA ANDRA
Project Description:
APN/TracVLot No:
Owner:
Contractor:
Applicant:
624300029
WDV INV
BRADSHAW CONSTRUCTION
BRADSHAW CONSTRUCTION
TR 21698
SURREY BC
INC
INC
23
CANADA V3S6K1,
81335 THUNDER GULCH WAY
81335 THUNDER GULCH WAY
LA QUINTA, CA 92253
LA QUINTA, CA 92253
(760)347-4246
(760)347-4246
Licensed ContractoLDmclaraSLon
Fee Summary
�!
by affirm under penalty of oeriury that I am licensed under provisions of Chapter 9
r.t-n-1-my
ARCHIVE FEE-8.5X11 UP TO 11X17 GI-4100000-3411600 $0.28
r
mencing with Sec:fen 7000) or Division 3 of the Business and Professions Code,
license is in full force and effect.
GREEN BLDG FEE S131473 GL-61000DO-2281000 $1,00
Initial
MINIMUM INSPECTION FEE GL-11000003221100 $159.00
PERMIT ISSUANCE FEE GL-1100000-3411400 $105.00
Owner -Builder Declaration
El1
hereby affirm that 1 am exempt from the Contractors' Stale
Total Fees Paid: $265.28
License Law for the reason(s) indicated below by the checkmark(s) I have placed next
to the applicable item(s) Section 7031.5 Business and Professions Code: Any city or
county which requires a permit to construct, alter, improve, demDhsh, or repair any
structure, prior to 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 Contractors' Stale
License Law(Chapter g(commencing with Section 7000) of Division 3 of the Business
and Professions Code) or that he or she Is exempt and the basis for the alleged
Print Name:
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the
applicant to a civil penally 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
SignafureofAppikanf or Agent:
an owner of property who builds or improves the property, 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 proNng that it was not built or improved for the purpose of sale.)
Date:
I, as owner of the property, am exctusiveiy contracting with licensed contractors 10
construct the project (Sec. 7044, Business and Professions Code: The Contractor's
License Law does not apply to an owner of property who builds or improves thereon,
and who contracts for such projects with a licensed contractor pursuant to the
Contractors' Slate License Law.)
I am exempt from Licensure under the Contractors' State License Law for the
following reason:
Dale/Signature of property owner or agent
Workers' Compensation Declaration
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 ADDRION TO THE COST OF COMPENSATION DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
I hereby alffirrownder the penalty of penury ONE of the following declarations:
I have and will maintain a certificate of consent to self -insure for workers'
compensation, issued by the Director of industrial Relations as provided for by Section
Initial
3700 of the Labor Code, for the performance of the work for which this permit issued.
�oilcy No.
n
!i
1 have and will maintain workers' compensation insurance, as required by Section
3700 of the Labor Code, for the performance of the work forwhich this permit is
issued. My workers' compensation insurance carrier and policy number are:
nitial
Carrier& Policy Number
Expiration Date
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 the workers'
compensation laws of Califomia and agree thatVshoulbecome subject to the
workers'compensation provisions of Se on 37Labo de, I shall forthwith
comply wi h those p)ss ns.i
Date Iplicant
Initial
/,
U
City of Palm Desert
Department of Building and Safety
Building Permit Application
(For Office Use Only)
JOB ID: F ZC � Oly
PLANS FILED:
Project Address: 23 Avenida Andra, Palm Desert 92260 Suite #
Total Value of work: $ $1000.00
Note: Plan Review Fees may be adjusted after Plan Review
Project Description (be specific): Temp power pole for Construction use
Contractor Business Name
Bradshaw Construction
Property Owner Name
Address 81335 Thunder Gulch Way
Address
city La Quinta Zip 92253
city Zip
Phone 760-347-4246
Phone
Fax
Fax
E-mail Kellypmarkbradshawconstruction.com
E-mail
Contractor License No.
848057
❑Architect Name ❑Designer Name
Engineer Name
Address
Address
city Zip
city Zip
Phone
Phone
Fax
Fax
E-mail
E-mail
License No.
848057
License No.
r
Applicant Name
Signatur
Date
Jonathan Van Alstine
Gt
3/28/18
Contact Telephone Number
E-Mail
760-766-6189
JonathanO.markbradshawconstruction.com
PLEASE COMPLETE THE REVERSE SIDE
73-510 Fred Waring Drive, Palm Desert, CA 92260 • (760) 776-6420 • (760) 776-6392 fax * www.cityofpalmdesert.org