09-0534 (BLCK)81307 Amundson Ave
09-0534
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P.O. BOX 1504 IE
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
T4ht 4 4 Q"
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Application Number:
09-00000534
Property Address:
81307 AMUNDSEN AVE
APN:
767-690-020- - -
Application description:
WALL/FENCE
Property Zoning:
LOW DENSITY RESIDENTIAL
Application valuation:
1440
Applicant: Architect or Engineer:
0 A
I hereby affirm under penalty of perjury
Section 7000) of Division 3 of the Busi
License Class: B
Date: ' L lqo Contractor:
;ED CONTRACTOR'S DECLARATION
licensed under provisions of Chapter 9 (commencing with
Professionals Code, and my License is in full force and effect.
License No.: 848057
OWNER -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 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 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 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 wh6 builds or improves thereon, and who contracts for the projects with a contractor(s) licensed
pursuant to the Contractors' State License Law.).
1 1 I 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:
LQPERNIIT
Owner:
MICHAEL H GRAY TRUST
81307 AMUNDSON AVE
LA QUINTA, CA 92253
Contractor:
BRADSHAW CONSTRUCTION INC
46248 ROUDEL LN
LA QUINTA, CA 92253
(760)347-4246
Lic. No.: 848057
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
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 nu er are:
Carrier DELOS INS Policy Number 01DKRM22005875
I certify that, in the performan of the work for which this permit is issued, I shall not employ any
person in any manner so a o become subject to the workers' compensation laws of California,
and agree that, if I should ecome subject to the workers' compensation provisions of Section
3700 of the Labor Code, shall forthwith comply with those provisions.
Date: Applicant:
WARNING: FAILURE TO SECURE WOR ERS' 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.
-7012
-7011
-7153
9/09
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.
I . 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. 1
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 abov formation is correct. I agree to comply with all
city and county ordinances and state laws relating to building nstruction, and hereby authorize representatives
of this county to enter upon the above-mentioned property f inspection purposes.
Date: gnature (Applicant or Agent).
Application Number . . . . . 09-00000534
Permit . . . . . WALL/FENCE
PERMIT
Additional desc .
Permit Fee . . . . 35.00
Plan Check Fee..
00
Issue Date . . . .
Valuation . . .
. 1440
Expiration Date 11/25/09
Qty Unit Charge Per
Extension
BASE
FEE
15.00
10.00 2.0000 HND BLDG
501-2,000
20.00
----------------------------------------------------------------------------
Special Notes and Comments
90 LN FT X 4 FT HT RETAING WALL
PER CITY
STANDARDS AND APPROVED PLANS.
--------7-------------------------------------------------------------------
Other Fees . . . . . . . . . BLDG
STDS ADMIN (SB1473)
1.00
Fee summary Charged
--------------------
Paid Credited
--------------------
Due
-----------------
Permit Fee Total 35.00
.00 .00
35.00
Plan Check Total .00
.00 .00
.00
Other Fee Total 1.00
.00 .00
1.00
Grand Total 36.00
.00 .00
36.00
LQPERMIT