PLBG (05-2129)51425 Madison St
05-2129
P.O. BOX 1504 ^' VOICE (760) 777-7012
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT. INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: _ 6/02/05
Application Number: (-05=00002.129 Owner.
Property Address: ---------------------------------
APN: 51425 MADISON ST STEARNS GEORGE P
Application description: 772:270-014- - - 51425 MADISON STREET
Property Zoning: PLUMBING LA QUINTA, CA 92253
Application valuation: , VERY LOW D
pContractor:
Applicant: Architect o der: ---------------------------------
ALMS UNDERGROUND CONST, INC.
JJ 38703'VISTA DRIVE
CATHEDRAL CITY,.CA 92234
CITYOFIA®IIINTA Lic. No.: 482180
FINANCE DEPT.
LICENSED CONTRACTOR'S DECLARATION WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chaptei 9 (commencing with 1 hereby affirm under penalty of perjury one of the following declarations: "
Section 7000) of Division.3 of the Business and Professionals Code, and my License is in full force and effect._ I have and will maintain a certificate of consent to self -insure -for workers' compensation, as provided
License Class: C42 -C21 License No.: 482180 for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
Tissued.
Date: J V ` f r. - 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
OWNER- LDER DECLARATION insurance carrier and policy number are:
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the Carrier AU INS Policy Number 00500023125 '
following reason (Sec. 7031 .5, Business and Professions Code: Any city or county that requires a permit to _ I certify that, in the performance of the work for which this permit is issued, I shall not employ any
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the person in any manner so as to become subject to the workers' compensation laws of California,
.permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State and agree that, if I should become subject to the workers' c pensation provisions of Section
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 3700 of the Labor e, I shall Z-7
ply with provisions.
that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by Y JC
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).: Date51; 1JhZDu Applicant: '
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 : WARNING: FAILURE TO SECURE WORKER OMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
Contractors' State License Law does not apply to an owner of property who builds or improves thereon, SUBJECT AN EMPLOYER TO CRIMINAL PEN LTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
and who does the work himself or herself through his or her own employees, provided that the DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
improvements are not intended or offered for sale. If, however, the building or improvement is sold within SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
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.). - APPLICANT ACKNOWLEDGEMENT
(_) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the
7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of conditions and restrictions set forth on this application. '
property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed 1. Each person upon whose behalf this application is made, each person at whose request and for
pursuant to the Contractors' State License Law.)., whose benefit work is performed under or pursuant to any permit issued as a result of this application,
(_) I. am exempt under Sec. , B.&P.C. for this reason 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.
.Date: Owner: 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
CONSTRUCTION LENDING AGENCY permit to cancellation.
-I hereby affirm under penalty of perjury that there is a construction lending -agency for the performance of the I certify that I have read this application and state that the above information is correct. I agree to comply with all
work for which this permit is issued (Sec. 3097, Civ. C.). _ city and county ordinances and state laws relating to buildi construction, a hereby uthorize repre ntat(ves
of this county to enter upon th above-mentioned propert 'nsp moon p ses.
Lenders Name:-!
ate:ZT-k nature (Applicant.orAger w"
LQPERMIT
LQPERMTT
Application Number . . . . . 05-00002129
Permit PLUMBING SEWER
Additional.desc .
Permit Fee 30.00
Plan Check
Fee
.00
Issue Date . . . .
Valuation
6000
Expiration Date 11/29/05
Qty Unit Charge Per
Extension
BASE FEE
30.00
Special Notes and Comments
SEPTIC ABANDON; SEWER CONNECT
Fee summary Charged Paid
---------- ----------
Credited
-------- - -----------
Due
------------------
--------------
Permit
Permit Fee Total 30.00
.00
7
.00
30.00
Plan Check Total .00
.00
.00
.00
Grand Total 30.00
.00
.00
30.00
LQPERMTT
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