10-1363 (BLCK)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: 10-00001363
Property Address: 81307 AMUNDSEN AVE
APN: 767-690-020- -
Application description: WALL/FENCE
Property Zoning: LOW DENSITY RESIDENTIAL
Application valuation: 825
Td4t 4 4 Q"
Applicant: ^ 11 Architect or Engineer:
014�
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
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LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury t t I am licensed under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Busin sand Professionals Code, and my License is in full force and effect.
License Class: B Lim No.: 848057
ate: 14 ntractor.
OWNER -BUILDER DECLARATION
1 hereby affirm under penalty of perjury that 1 m exempt from the Contractor's State License law for the
following reason (Sec. 7031 .5, Business and rofessions 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 1, 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.).
(_) 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.).
(_) 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: 1 I ►/ ,
Lender's Address: ju
Owner:
MICHAEL H GRAY TRUST
PO BOX 9935 �, u
NEWPORT BEACH, CAj�tj58
Contractor:
BRADSHAW CONSTR CTI
46248 ROUDEL LNL-_
LA QUINTA, CA 92253
(760)347-4246
Lic. No.: 848057
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 12/13/10
•----------------------------------------------
WORKER'S 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.
R I have and will maintain rkers' compensation insurance, as required by Section 3700 of the Labor
Code, for the perform a of the work for which this permit is issued. My workers' compensation
insurance carrier and o�icy number are:
Carrier DELOS INS i Policy Number 01DKRM22005875
_ I certify that, in the perf anca of the work for which this permit is issued, I shall not employ any
person in any manner as to become subject to the workers' compensation laws of California,
and agree that, if I sh become subject to the workers' compensation provisions of Section
3700 of the Labor C I shall forthwit comply with those provisions.
te: 1�'t' Applipet:
WARNING: FAILUR TE WORK S' 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.
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 pu 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 Ouinta, its officers, agents and employ as for any act or omission related to the work being
performed under or following issuance of thi permit.
2. Any permit issued as a result of this applicat n becomes null and void if work is not commenced
within 180 days from date of issuance of s h 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 ove information is correct. I agree to comply with all
city and county ordinances and state laws relating to buildi construction, and hereby authorize representatives
of this county to enter upon the above -mentioned prope or inspection purposes
JJ 111)0 /ignature (Applicant or Agent):
Application Number . . . . 10-00001363
Permit . . . WALL/FENCE PERMIT
Additional desc . .
Permit Fee . . . .
23.00 Plan Check
Fee
.00
Issue Date . . . .
Valuation
. . .
. 825
Expiration Date . .
6/11/11
Qty Unit Charge
Per
Extension
BASE FEE
15.00
4.00 2.0000
HND BLDG 501-2,000
8.00
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Special Notes and Comments
40 L.F. COMBO WALL 2'
8" RETAINING, 314"
GARDEN, CITY STANDARD.
2007 CODES.
----------------------------------------------------------------------------
Other Fees . . . . .
. . . . BLDG STDS ADMIN (SB1473)
1.00
Fee summary Charged
Paid Credited
Due
---------------------------
Permit Fee Total
--------------------
23.00 .00
----------
.00
23.00
Plan Check Total
.00 .00
.00
.00
Other Fee Total
1.00 .00
.00
1.00
Grand Total
24.00 .00
.00
24.00
LQPERMIT
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Bin #
City of La Quinta
Building 8r Safety Division
P.O. Box 1504, 78495 Calk Tampico
!.a Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
V
Project Address:
Owners Name:
A. P. Number:
Address: -,-"
Legal Description:
City, ST, Zip: �t t
Contractor: -19'4014$ UAa
Telephone:
Address: %4,G - 2, g L (-,a,��
Project Description:
City, ST, Zip: L-A-
Telephone: " (.o- 3�i 2WEE=
State Lie. #: City Lie.
Arch., Engr., Designer:
Address:
e�
City, ST, Zip:
Telephone: Construction Type: Occupancy:
State Lie. #: Project type (circle one): New Add'n Alter Repair Demo
Name of Contact Person: Sq. Ft.: #Stories: #Units:
Telephone # of Contact Person:
Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Reed
TRACE NIG
PERMIT FEES
Plan Set:
Plan Check submitted
Item Amount
Structural Caics.
Reviewed, ready for corrections
Plan Check Deposit
Truss Cala.
Called Contact Person
Plan Check Balance
Tide 24 Cales.
Plana picked up
Construction
Flood plain pin
Plans resubmitted
Meehan"
Grading plan
2'! Review, ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
''' Review, ready for correctioustissue
Developer Impact Fee
Planning Approval
Called Contact Person
A.LP.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees