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04-6649 (BLCK)ac r 4 BUILDING & SAFETY DEPARTMENT P.O. Box 1504 (760).777-7012 7814M ;CALLE TAMPICO • ,W� ? FAX (7-60) 777-7011 LA �UINTA;,:;CALIF0,RNIA'92253 INSPECTION.REQUESTS,(760)=777-7153 r 1 204 BUILDING: PERMIT of r`anr .ApplV. ycatt�i�on�Number 04-00006649 Date 10/14/04 Property Address . . . . 5,240T0 AVENIDA OBREGON APN:., 773=2515 -006. -.6 -000000 - Application description. WALL/FENCE,,.- Property Zoning . . COVE`RESIDENTIAL Application valuation 6876 Owner Contractor PLASCENCIA GUDELIA S Owner 52400 AVENUE OBREGON LA QUINTA, CA•92253 "'. (760) 70:2=0166 --------.------- Application Number 04-00006649`` ' ---------------- --------------- Permit . . WALL/FENCE PERMIT j� r Additional desc Permit Fee 96.,o0 Plan Check.Fee. 00 Issue Date Vai'zaton 6876 Expiration Date 4/14/0'5• Qty . Unit Char e Per.. ,. 9 . Extension BASE FEE'' 45.00 5.00 9.0000 THOU BLDG 2,001:-25,000 ------------------------- 45.00 .---------- --------- -------------------- Special Notes -and Comments 10 LF 5' :BLOCK WALL AND, 90 LF' 6' - BLOCK WALL ALONG --BOTH SIDE :PROPERTY • L'i,NES/:50. " LF 6' BLOCK WALL`@ REAR PROPERTY LINE/32 LF 5' BLOCK WALL ALONG ,FRONT PROPERTY LINE. ALL PER�!ORCO"bETAIL. Fee summary Charged Paid ;Credited Due ---- .Permit Fee Total, 90..00 0,0 .00 ---------- 90.00. Plan. Check Total .-00 ..00 : 00 . 00 Grand Total90.00 .:00 .00 90.00 M1' P.O. Box 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT Application Number: 0 'F' Applicant: Applicant's Mailing Address: Architect or Engineer: VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: / 0 -71Y�-v Architect or Engineer's Address: Lic. No.: BUILDING PERMIT DECLARATIONS LICENSED CONTRACTOR'S DECLARATION 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 License No. Date Contractor OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county that requires a permit td 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 Contractors' 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).): U 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 or 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.). U 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(s)licensed pursuant to the Contractors' State License Law.). U I am exempt under Sec. ,/BA P.C. for this reason C Date �d lu'�LI Owner J l%!Ct SSP �/Ji'iGL WORKERS' 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 poligy number are Carrier /VCI,IQYLT'�,Rluyg,,,C� ['�. Policy Number ftl /, in re, ? _ 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 California, and agree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Date 10 l U `d �/ Applicant6-yge /( ''C S .f% // S`ce y1C i 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. CONSTRUCTION LENDING I hereby affirm under penalty of perjury that there is a construction lending age cyorJthe performance of he work for which this permit is issued (Sec. 3097, Civ. C.). Lenders Name Lenders Address ACKNOWLEDGEMENTAPPLICANT IMPORTANT Application is hereby made to the Director of Building and Safety for permit G 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 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—ID—l9`Qg Signature (Applicant or Agent): (OIJdh - / a C , Q/- I 0/a :RENEWAL Newport:Insurarice Company BALBOA P.O:• Box 25140 • Santa'Ana; CA 92799-51,40: LIFE a CASUALTY - HOMEOWNERS ,POLICY 'DECLARATIONS Mail To: Named'I'nsured: 135-1017 GVDELIA $ STROUD GUDELIA S STROUD 52400.AVENIDA OBREGON 52400 AVENIDA OBREGON .LA QUINTA, CA 92253 LA.QUINTA, CA 92253 . Covered Property: Agent• 52400 AVENIDA OBREGON'L COUNTRYWIDE INS SERVICES, INC. LA QUINTA, CA 92253 994.17LOWER GLEN SIMI..VALLEY, CA 93065- Agent 3065Agent Code:° 584002 For Customer Service Call: (800) 894-0976 For Claims Call: (888) 768-2096 4 Policy -Number Company Program` THN 000115743 Newport Insurance C6mpany. Preferred' Policy Period From: 05-16-04 To: 05.-16=05 12:01 A.M. STANDARD.TIME AT THE ADDRESS- OE THE RESIDENCEPREMISES Coverages Limits of. -Liability Premium Section I Coverage A - Dwelling. $131,0.00 $655.00 Coverage B - Other Structures $13;100 Coverage C - Personal Property $86,500;. $45.00 Coverage D - Loss of Use, $2`6;200 Section II Coverage E - Personal Liability (each occurrence) $300;000 $15.00 Coverage F - Medical Payrnents.(each person)'' .. $1,000 Deductible All Peril Deductible (Section I) $500.00 INSUREWCOTY Page 1 of 2 sI KK ne :_? NSATION NOTICES California Residential Property Insurance Disclosure Privacy Notice Total Premium $840.00 Important Information Policy includes Coverage for Ordinance or Law POLICY DOES NOT INCLUDE FLOOD OR EARTHQUAKE COVERAGE Discounts Applied Protective Device Other Interest Mortgagee COUNTRYWIDE HOME LOANS, INC PO BOX 10212, MSN SV -22 INS DE VAN NUYS, CA 91410 Loan Number 4894954 INSURED COPY bmind Mon.: 03n7nnn4 Page 2 of 2 0 Policy Forms and Endorsements Form Number Form Description Premium HO 00 03 04 91 HOMEOWNERS POLICY -SPECIAL FORM HO 0104 02 00 SPECIAL PROVISIONS -CALIFORNIA HO 04 96 04 91 NO SEC II FOR HOME DAY CARE ' H215J R1099 POLICY JACKET H260E R1099 ADDITIONAL COVERAGES H431E E0301 ACTUAL CASH VALUE DEFINITION H452EOO E0502 MOLD AND FUNGI LIMITATION - SECTION I $5000 - SECTION II $25,000 INC H518E OOE0903 ACTUAL CASH VALUE 438 BFU NS LENDERS LOSS PAYABLE 4H262E E1099 EXTENDED REPLACEMENT COST $5.00 - 4H261E E1099 MORTGAGE PAYMENT PROTECTION $7.00 HO 04 90 04 91 PERSONAL PROPERTY REPLACEMENT $113.00 HO 90 7 82 WORKERS COMPE NSATION NOTICES California Residential Property Insurance Disclosure Privacy Notice Total Premium $840.00 Important Information Policy includes Coverage for Ordinance or Law POLICY DOES NOT INCLUDE FLOOD OR EARTHQUAKE COVERAGE Discounts Applied Protective Device Other Interest Mortgagee COUNTRYWIDE HOME LOANS, INC PO BOX 10212, MSN SV -22 INS DE VAN NUYS, CA 91410 Loan Number 4894954 INSURED COPY bmind Mon.: 03n7nnn4 Page 2 of 2