05-2635 (PLBG)P.O. BOX 1504
78-495 CALLE TAMPICO "
LA QUINTA, CALIFORNIA 92253
Application Number: (05'0.0002635
Property Address: 516.0`5 VA ENIDA_ OBREGON
APN: 773-123-015-5 -000000-
Application description: PLUMBING
Property Zoning: COVE: RESIDENTIAL
Application valuation: 170 %\
Ta�v °f �Q�w
Applicant.: hitect or Engineer:
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
.•
LICENSED CONTRACTOR'S DECLARATION -
I hereby affirm .under penalt pepurythat I•am licensed under pcowsions of Chapter°9 (commencing with
Se6tion'7000) of. Division 3 of the, Business end.Professionals Code; m
and'ydLicense is in full fixce and effect.
License Class: C36 Licehse No.: 828264.
DateContiactor: -
�M
4- s
-' ,';,.. OWN BUILDER DECLARATION * -
I hereby affirm under penalty of;perjurythat I am'exempt.from;ttie Contractor's State:bcense Law.for the;.
following reason (Sec. 7031'.5,Biisiness and Professions Code:"Anyiity''orcounty that regwres`wpermn to:, .
construct; -alter improve, demolish;, .8r repair.anystructure; priorto 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 (c6mmencing.with.Section)00Q)of Divn heisio3'of tBusiness and Professions Code) or
-that he or-sne.is exempt therefrom and the basis fortfie alleged exemption, "Any violation. of Section 7031.5 by
any applicant for a permit subtects.the applicant toa civil penalty of not more than frve'hundreddollars ($500).:
1 _ 1 I, as owner`oI the property; or my employees with wages as theirsole compensation, will do the'woik, and '
the structure is not'int6nded or'offered'for sale (Sec..7044 Business and Professions Code The: .
Contractors' State License Law does not epply'to-an owner of property who builds or improves ttiereon;
and who does the, Work himself or heiself 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 ofproving that 1 e or she did not build or
-improveJor the purpose of sale:). ` - �' � `•e
(_ 1 I, as owner of the property, am exclusively contracting. with licensed contractorsto construct the project (Sec.
7044, Business and Professions Code: .The Cont ractorst-State License Law does not apply to:ari owner of
property who builds orimproyesthereon, and who.contraat for the projects with a.contractor(s) licensed
pursuant. to the Contractors' -State License Law.): -
1 _) I am.6empt 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: 1
LQPERMIT
Owner:
WARD RUSSELL
P O BOX 735
51605 AVENIDA OBREGON
LA QUINTA, CA 92253
Contractor
FOY, SCOTT A.
79-499.COUNTRY CLUB ,DR STE.9
"INDIO CA 92201
(760)360-0927
No.: 828264
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS. (760) 777-7153
Date: 6/28/05
• WORKER'S COMPENSATION. DECLARATION
hereby affirm under penalty of perjury one of.the following declarations:
I have and will maintain a certificaie,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 IIhs, permit is
issued .
,. ,. I trove and will maintain workers -compensation-insurance, as required by Section 3700 of the'Labor
.Code ,forthe performance ofthe work for'which this permit is cssu`ed My'workers' compensation
. insurance' carrierand,policy numberarei '" ,.,;,, '•+
Carrier STATE -FUND,; r ;Policy Number .'1576841V.
I certifythat, in the performance of the work for whichthis permit ..isissued, 'I shall not employ any
person in•ahy mannerso as to become subject to.the workers"compensation laws of California, •
and agree that, if I should become subject to the workers compensation•provis_ions of Section
3700 of the Labor Code,. I shall forthwith to
with those provisions.
Date: L� 8/V � Applicant:
may_ _ ,.—ter• �.p-'
. WARNING:' FAILURE TO. SECURE WORKERS' COMPENSATION COVERAGE• IS UNLAWFUL, -AND SHALL
SUBJECT AN EMPLOYER TQCRIMINAL•PENACTIESAND CIVIC FINES UPTO ONE HUNDRED THOUSAND
DOLLARS (5100,DOO)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 Applicationis hereby made to the Director of Building,and Safety for apermit'subject to the
conditions and restrictionsset forth on thi§application. S
1 . Each person, upon whose behalf this application is made, each person'at whose request and for
` whose benefit work's performed under or-pur§uant 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 issuanceof 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 issuanc"e-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 pro y for inspection pur oses.
Da� Signature -(Applicant -or -Agent), i c
'
Application Number . . . . . 05-00002635
Permit. . PLUMBING
Additional desc .
Permit Fee . . . . 22.50 Plan Check.Fee
.00
Issue Date Valuation
. . .
. 0
Expiration Date ., 12/25/05
Qty Unit Charge Per
Extension
BASE FEE
15.0.0
1.•00 7.5000 EA --.PLB WATER HEATER/VENT
7,.50'
-------------------------------------------
Special Notes and -:Comments
Hk Tth-REPLACEMENT
Fee summary Charged Paid Credited
Due
_--------- --- - ------ ------------
Permit Fee• ,Total 22 : 50 "- 00
------------
.00 .'
-'22.50
_
Plan, Check •Total 00 . 00.:: ..
.0 0
. 00
4.
Grand Total ... 22::50:. ., 00-
:'00'
22.50
LQPERMIT' ..