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04-6625 (BLCK)�� LLL✓✓✓ _ .T_ '" t CP L/4 11 C��.' � BUILDING & SAFETY DEPARTMENT —P- . (760).777-7012 78-4.95' CALLE TAMPICO FAX (760) 777-701 1 LA QUINTA, CALIFORNIA 92253 INSPECTION REQUESTS (760) 777-7153 BUILDING PERMIT Application Number . . . . . 04-00006625 Date 10/05/04 Property Address . . . . . . 77985 AVENIDA MONTEZUMA APN: 773-10.4-036-24 -000000- Application description WALL/FENCE Property Zoning . . . . . . . VILLAGE COMMERCIAL Application valuation . 243 Owner Contractor ------------------------ 77 ------------------------- LADOUCEUR JACKIE G SCRIVENS'CONSTR, INC., G.L. P O BOX 703 61400 YUCCA ROAD .LA QUINTA CA 92253 MOUNTAIN CENTER CA 92561 (760) 349-3327 WCC: STATE FUND WC: 807645 01/01/05 CSLB: 807645 05/31/06 CCC: B ----------------------------------------------------------------------------- Permit . . . . . . WALL/FENCE PERMIT Additional desc Permit Fee . . . . 15.00 Plan Check Fee .00 Issue Date . . . . Valuation 243 Qty Unit Charge Per Extension BASE FEE 15.00 =-----------------------------------------------------------7--------------- Special Notes and Comments TRASH ENCLOSURE, 7LF GARDEN BLOCK WALL, (CITY STANDARD) W/PAIR 4060 METAL GATES. Fee summary Charged- Paid Credited Due Permit Fee Total 15,00 .00 .00 15.00 Plan Check Total .00 .00 .00 .00 Grand Total 15.00 ..00 ..00 15.00 P.O. Box 1504 �� 78-495 CALLS TAMPICO VOICE (760) 777-7012 LA QUINTA, CALIFORNIA 92253 4 4 FAX (760) 777-701 l • INSPECTIONS (760) 777-7153 BUILDING & SAFETY DEPARTMENT Application Number: Applicant: Hppncanrs Mailing Address: Date: Architect or Engineer: Hrcrinect 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 Licens is in full force and effect. License Class_ L License No. Date Contractor /✓[?✓ I' < * _J-7, /-v L 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 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 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 issuec�M wgtcers' com nsation insurance carrier and lic number a� Carrier �Jr1l �/�__A, G7 Policy Number _ ��( �! 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. �? _ WARNING: FAILURE TO SECURE WORKERS' CO g4ATION 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 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 Lenders Address IMPORTANT Application is hereby made to the Director of Buildingand SafetyCAAPPLICANT ACKNOWLEDGEMENT forato the co set forth on this application. 1. Each person upon whose behalf this application is made, edch person at whose request and for hose benefit orkrons 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 informatio 's correct. I agree tomply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to ent n t above -me ned property for inspection purposes. i Date�O Signature (Applicant or Agent): NALL t+ Approved b . 0 Planning Commission Vity Council Community Dev Dept. Initials Case No. Exhibit O With Conditions IV,A5 W-V^WL•- Date Peso # La Quinta Ca. 92234:x., ; s 760-668-1964^., yt C 0 . MARK DATE I DESCRIPTION PROJECT NO: 332003 CAD FILENAME: 77985 Montezuma1.lbk DESIGNED BY: Sipovac Const: Inc. DRAWN BY: Bob Sipovac CHECKED BY: Sipovac Const. Inc. COPYRIGHT: Sipovac Const. Inc. DATE Thursday, September 30, ; SHEET TITLE SITE TRASH