05-4523 (BLCK)P.O. BOX 1504
78-495'CALLE TAMPIC0
LA QUINTA, CALIFORNIA 92253
Application Number:
Property Address:
APN:
Application description:
Property Zoning:
Application valuation:
Applicant:
05-000_04523.
51855 AVENIDA MORALES
773-151-005-5 -000000-
WALL/FENCE •
COVE RESIDENTIAL
3550
Architect or
alp
T4iyl
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
------------------
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 License is in full force and effect.
License Class: License No.: .
Date: Contractor:
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's 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 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 I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and
Y 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 con ruct the project (Sec.
7044, Business and Professions Code: The Contractors' State License Law doe t apply to an owner of
property who builds or improves thereon, and who contracts for the projects i a contractor(s) licensed
pursuant to the Contractors' State License Law .l.
I—) I am exempt under Sec. , B.&P.C. for this
Date: 6 0 •/ 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 ISec. 3097, Civ. C.).
Lender's Name:A,
A .
Ja
Lender's Address: IIS i
LQPERMIT
Owner:
MILLSPAUGH RONALD M
53665 AVENIDA VELASCO
LA QUINTA, CA 92253
Contractor:
Owner
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
WORKER'S COMPENSATION DECLARATION
Date' 10/07/05
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 issued. My workers' compensation
insurance carrier and policy number are:
Carrier Policy Number
9Lcertify that, in the performance of the work for which this permit is i ued, I shall not employ any
person in any manner so as to become bje t to the workers' pensatio ws of California,
and agree that, if I should become s lec the work@rs' nsa ' p visions of Section
0-11t
� // 7 3700 of the Labor Cod hall f w' co ply with i s r on
ff'Datape plicanY.
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION AGE 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 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 com nced
within 180 days from date of issuance of such permit, or cessation of work for 7.;�eprp6ntatives
will ct
permit to cancellation.
I certify that I have read this application and state that the above infor tion is correct. I ogrVor l with all
city and county ordinances and state laws relating to building ons[ ti , and hereby aut
of this county to ente�on the above-mentioned props i p ses.
15
`Pate: rs i , r Sig�re (Applicant or Agentl:
Application Number
.. . . . . 05-00004523
Permit. . .
. WALL/FENCE PERMIT
Additional desc .
Permit Fee
63.00
Plan Check Fee
.00
Issue Date
Valuation . . .
. 3550
Expiration Date
4/05/06-
/05/06Qty
QtyUnit Charge Per
Extension
BASE FEE
45.00
2.00 9.0000 THOU BLDG 2,001-25,000
18.00
Special Notes and Comments
142 L.F. 6' GARDEN
WALL, CITY STANDARD
Fee summary
Charged Paid
Credited
Due
Permit Fee Total
63.00
.00 .00
63.00
Plan Check Total
.00
.00 .00
.00
Grand Total
63.00
.00 .00
63.00
i
LQPERMrr
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