04-7595 (RPL)lr,
BUILDING .& SAFETY DEPARTMENT
.P:O. Box 1504(760)777-701.29
Koi
78-495 CALLE TAMPICO FAX (760) 77777011
LA QUINTA, CALIFORNIA 92253 INSPECTION REQUESTS (760) 777-7153
BUILDING PERMIT
Application, Number 0,44 00007_595
Date 12/06/04
Property Address 5253-0 AVENIDA OBREGON.
APN: 773-285 ,002. -,1_ -.00.0000 -
Application description. ...., �,POOL�. 4RESTDENTIAL '
Property.Zoning COVE.REST•DENTIAL
.Application valuation 125:0'0
Owner Contractor.
MTB MTB INC.
50855 WASH INGTOS'T-RE'ET•—#•=149 ,; 50855 -_WASHINGTON
ll -U92253
ST STE 14-9
LA QUINTA:- C LA QUINTA
CA 92253
(760)' 272-6044
DE% 3 2004 WCC - STATE FUND
`WC 1795095-2004
08/01/05
CITNa�:CSLB-:', 838089
.05/31/06
F.INtANCE 0t0_ CCC: B
Permit . . . . BLDG POOL PERMIT
Additional desc.. -
Permit Fee .144-.00 Plan .Check 'Fee
93.60
Issue Date Valuation . .
. . 12500
Qty Unit Charge Per
Extension
BASE_FEE.
;45.00
11.00 9.0000 THOU BLDG 2.;001-25,.,000 •
99..00
Permit MECH POOL -
Additional desc
Permit Fee 24:0'0Plan Check Fee
6.00
Issue Date Valuation
0
Qty Unit Charge Per.....
Extension
BASE..,,TEE'
15.00
1.00 9.0.0.00- EA- ME CH,", FURNACE <='�100K.
9.00
Permit . . . ELEC POOL PERMIT :-.•RES ..:. -
Additional desc
Permit Fee . . . . 45.'0.0... Plan Check Fee
11.25
Issue Date Valuation
0
Qty Unit -Charge Per
Extension,
BASE FEE'
15.'00
1.00 30.0000.: EA ELEC PRIVATE. SWIMMING POOL
30.00
Permit . . . . . .. ..PLUMB'ING
Additional desc
Permit Fee' `33.00 �Plan Check Fee
8.25
P.O. BOX 1504 • '• ��IIG�
78-495 CALLE TAMPICO Irl
LA QUINTA, CALIFORNIA 92253 4
BUILDING & SAFETY DEPARTMENT
Application Number:
Applicant:
Applicant's Mailing Address:
Architect or Engineer:
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date:
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
/ - , and ss License in full force and effect. L -3�a . 9
icense Class icense No.
at
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 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 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 fora 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.).
L) I am exempt under Sec. , BA P.C. for this reason
Date
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 rkers' compensation ance carrier and policy number are:
arrier SY-C� tJ�'� Number % ?9 C"aDd
I certify that, in the performance of the work for which this permit is issued, 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. /)
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE I�-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 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 Q
Lender's Address 1 1
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 Ouinta, 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 prop or p ction purposes.
ate
Signature (Applicant or Agent):-�/
-
l
Page 2
Application Number**:': 04-.0:000759,.5 .
Date 12/0'6/04
Issue Date Valuation,,
0
Qty Unit Charge Per
Extension
BASE FEE
15.00
2.00 6 .. 0 0 0 0 "EA PLB :;F I.XTURE- .:
12.00
1.00 3.0000 EA PtB WATER INST/ALT/R,EP
3.00
1.00 3:00,00 EA PLB-'GAS PIPE. -1-4 .-OUTLETS
3.00
Special Notes and .Comments
POOL/SPA: ALARMS/BARRIERS SHALL BE IN
PLACE AT PRE -PLASTER INSPEC'T'ION.
EQUI`,PMENT ENCLOSURE NOT INCLUDED
Fee summary Charged Paid Credit -ed
Due
-------------
Permit _Fee Total, 2'46 ,,00; 0:0 00..
246.00
P1an Check.Total 119.10 :0.0 .00
119.10
Grand'Total 365..10 :0`0 .00
365.10