05-1291 (BLCK)P.O. Box 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING PERMIT
BUILDING & SAFETY DEPARTMENT
(760).777-7012
FAX (760) 777-7011
INSPECTION REQUESTS (760) 777-7153
Application Number . . . . .
05-00001291 Date
4/07/05
Property Address
80391 AVENUE 52
APN:
772-410-038- - -
Application description . . .
WALL/FENCE
Property Zoning . . . . . . .
LOW DENSITY RESIDENTIAL
Application valuation
875
Owner
------------------------
Contractor
ND LA QUINTA PARTNERS
------------------------
DIXON MASONRY, R.V.
375 N FRONT ST STE 200
P.O. BOX 11733
COLUMBUS OH 43215
PALM DESERT
CA 92255
_.
(760) 346-7802
WCC: STATE FUND
WC: 2290026048
03/01/06
CSLB: 355332
02/28/07
CCC: C29
-------------------=--------------------------------------------------------
Permit . . . . . . WALL/FENCE
PERMIT
Additional desc .
Permit Fee 23.00'
Plan Check Fee
.00
Issue Date . . . .
Valuation
875
Expiration Date 10/07/05
Qty Unit Charge. Per
Extension
BASE
FEE
15.00
4.00 2.0000 HND BLDG
-----------------------------------------------------------------------------
501-2,000
8.00
..Special Notes and Comments
35 L.F. 6' BLOCK WALL,ORCO SYSTEM,
3, 8 -
MASONRY COLUMNS @ 9' PER CITY APPROVED
PLANS.
Fee summary Charged
----------------- ----------
Permit Fee Total 23.00
Plan Check Total .00
Grand Total 23.00
Paid Credited-. Due
---------- ---------- ----------
.00 .00 23.00
.00 .00 .00
.00. .00 ___'F-3.00
D
D
APR p � 2005
CITY OF,rc
IIIIIIIIIIIIIIIIIIIIIIIII 29
IE
P.O. Box 1504
78-495 CALLS TANPtCO VOICE (760) 777-7012
� FAX (760) 777-701 I
LA Qu1NTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153
BUILDING tit: SAFETY DEPARTMENT
Application Number: (JJr — 1.. 9 / Date:- . OS
Applicant: I Architect or Engineer:
Applicant's Mailing Address:
Arcnnect or tngineer's Address:
Lic. No.:
BUILDING PERMIT DECLARATIONS
A/i�
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
Cade. and my License is in full force and effect. /"
License Class C-9 9 License N? m3- �2
=,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 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 for a permit subjects
the applicant to a civil penalty of not more than five hundred dollars ($500).):
U 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 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.).
e projects w
U I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Co
State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the a contractode: The, Contractors'
r(s) licensed pursuant to
the Contractors' State License Law.).
U 1 am exempt under Sec. , B:8 P.C. for this reason
Date Owner
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
�jssu d. orkers' ompensation insurance carrier a polic riumt er are:
Carrier (/ i yr `°<%,1 ., ; ,.
Policy Number. :...;��
_ I certify that, in the performance of the work for which this permit is issued, IIsshhall not employ P y an y 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.
D t ��i%� F.aplica
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
I hereby affirm under penalty of perjury that there is a construction I nd ng age cyothe performance of he work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
APPLICANT
IMPORTANT Application is hereby made to the Director of Buildin and SaCKNOWLEDGEMENT
ACKNOWLEDGEMENT
set forth on th . is
1. Each person upon whose behalf this application is made. each person at wehosfe request and for o whose benefitwork isnperformed under or pullrsua t 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.
1 certify that I have read this application and state that the above information is correct. 1 agree to cpmply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives of this county to enter upon t e ove-menti rfed property for inspection u
p rposes.
Date •' r 0 Signature (Applicant or Agent):