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SOTB (05-2995)57325 Madison St Lot F 05-2995 a;. P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: [0.5-00002995 Property Address: 57325-MADI65N ST LOT F APN: 762-240-003-F -300961- Application description: STRUCTURES OTHER THAN BUILDINGS Property Zoning: MEDIUM DENSITY RES - Application valuation: 3200 Applicant: 4 BUILDING & SAFETY DEPARTMENT BUILDING PERMIT Architect or Engineer:1ID VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 , p t-VDc '?PT LICENSED CONTRACTOR'S DECLARATION WORKER'S COMPENSATION DECLARATION Date: 11/0.1/05 I hereby affirm under penalty of perjury one of the following declarations: Owner: I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided License Class: License No.:. PUERTA AZUL PARTNERS - for by Section 3700 of the Labor Code; for the performance of the.work for which this permit is ' Date: Contra tor. V _ L 1 1 SI 17700 -SW UPPER BOONES FERRY RD t Code, for the performance of the work for which this permit is issued. My workers' compensation SUITE 100 insurance carrier and policy number are: _ I hereby affirm under penalty of perjury that 1 am exempt from the Contractor's State License Law for the PORTLAND, OR 97224 f Q Contractor: _ I'certify that, in the,performance of the work for which this permit is issued, I shall. not employ any Q RIPARIAN ENVIRONMENTS 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' compensation provisions of Section WCC: STATE FUND NOV Uo that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by WC: 1769754-2005' 05/01/06 7117YOF 1AUr. - CSLB:',' 839002 05/3.1/06 , p t-VDc '?PT LICENSED CONTRACTOR'S DECLARATION WORKER'S COMPENSATION DECLARATION ' I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with _ I 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: License No.:. - for by Section 3700 of the Labor Code; for the performance of the.work for which this permit is ' Date: Contra tor. V _ L 1 1 SI /`YJ(\ issued. — I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor f ' t t Code, for the performance of the work for which this permit is issued. My workers' compensation ' OWNER -BUILDER DECLARATION insurance carrier and policy number are: _ I hereby affirm under penalty of perjury that 1 am exempt from the Contractor's State License Law for the Carrier C8 C27 C29 C53 Policy'Number - - - - - - - - - - - - - - - - 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' compensation 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 Ccloe, I shall forthwith comply with those provisions. 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).: Date: 1 0- Applioerit: ' •` 1"ZiCA4/V ' 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 WORKERS' COMPENSATION 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 PENALTIES 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 (S 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 (_) I, 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—) 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 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: LQPERMIT .. of La Qumta, 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 ce that I have read this application and state that the above information is correct. I agree to comply with all y and county.ardinances and state laws relating wilding construction, and hereby authorize representatives of this counY to enter upon the above -mention prope y for inspection purposes. Date: t ` J Signature (Applicant or Ager LQPERMIT Application Number_ . . . ., 05-00002995 Permit BUILDING PERMIT Additional desc . Permit -Fee 19.00 Plan Check Fee 12.35 Issue Date Valuation 700 Expiration Date 4/30/06 Qty Unit Charge Per 'Extension BASE FEE 15.00 2.00 -2.0000 HIND BLDG 50172,000 4:00.. Permit BUILDING PERMIT Additional desc . Permit Fee 54.00 Plan Check Fee 35.10 Issue Date Valuation . . 2500 Expiration Date 4/30/06 . Qty Unit Charge Per Extension BASE FEE 45.00 „ 1.00 9.0000 THOU BLDG 2,001-25,000 9.00 Permit . -ELEC-MISCELLANEOUS Additional desc . Permit Fee 15.45 Plan Check Fee 3:86 Issue Date Valuation . . . 0 Expiration Date 4/30/06 Qty Unit Charge Per Extension BASE FEE 15.00 1.00 4500 EA ELEC DEVICE/FIXTURE >20 .45 Permit PLUMBING Additional desc . Permit Fee 18.00 Plan Check Fee 4.50 Issue Date . . . . Valuation . . . . 0. Expiration•Date 4/30/06 Qty Unit Charge Per Extension BASE FEE 15.00 1.00 3'.0000 EA PLB GAS PIPE 1-4 OUTLETS 3:00 Special Notes and Comments WATERFEATURE; 28 L.F. 6' TO 8' BLOCK WALL, ORCO SYSTEM; & TWO COLUMNS. Other Fees . ... . . ---------------------------------- . . . . ENERGY REVIEW FEE ------- 4.75 Application Number 05-00002995 Fee summary Charged Paid Credited Due \ ----------------- Permit Fee Total ---------- 106.45 ---------- .00 ---------- ---------- .00 106.45 Plan Check Total 55.81 .00 .00 .55.81 Other Fee.Total 4.75 .00 .00, 4.75 Grand Total 167.01 .00. .00 167.01 - f e ' LQPERMIT - - .