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05-3524 (PLBG)P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 �i Application Number: 05 00003524. Property Address: 46910 HIGHLAND PALMS DR APN: 643-193-006-20 -2117 Application description: PLUMBING Property Zoning: LOW DENSITY RESIDENTIAL Application valuation: 500 c&444Q"_ BUILDING & SAFETY DEPARTMENT BUILDING PERMIT Applicant: Architect or Engineer: ------------------ 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 a�nny��PPPPplicant 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 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.). (_ 1 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 contractorls) licensed pursuant to the Contractors' State License Law.). 1 _ 1 I am exempt under Sec. , B.&PjT. for this reason 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 Owner: STEPHEN M ROUCH 46910 HIGHLAND PALMS DR LA QUINTA, CA 92253 ( Contractor: Owner" VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 8/09/05 WORKER'S COMPENSATION DECLARATION 1 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. Ili 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 Qnsy�anc arrier and policy number are: /�� ^vim_ 4 Carrier -`-/°F- - - - --- - -- - -- Policy Number VY�� / �� 1 I 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 370000 of the Labor Cod shall f w' h comply with those provisions. DateJ r J- -0) Applicant: j WARNING: FAILURE TO SEC ORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO MINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADD ION 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 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 tha&theiation is correct. I agree to comply with all city and county ordinances and state laws relating toon, and hereby authorize representatives of this%county/to�enprupon the above-mentioned prorposes. Date:Signature (Applicant or Age Application Number 05-00003524 r Permit ... . PLUMBING SEWER Additional desc . Permit Fee" . . . 30.00 Plan Check Fee .00 Issue Date Valuation . . . 500 Expiration Date 2/05/06 Qty Unit Charge Per Extension BASE FEE 30.00 ----------------------------------------- Special Notes and Comments -- ------------------------- SEPTIC ABANDONEMENT-SEWER CONNECT.. Fee summary Charged Paid Credited Due -- -------------- Permit Fee Total. 30.00 ---------- .00. ---------- .00 _ 30.00 Plan Check Total .00, .00 .00 .00 Grand Total 3.0.00 .00 .00 30.00 LQPERMIT ! � 1 �.,. s�n.I�P,�l.•'.'.;�Y�i.�1�M.��# vl ''�., Iii t1&' N�.��P��a� 1 ' COACHELLA VALLEY WATER DISTRICT CASH RECEIPT DETAIL 1,1904 r+ 'Received From: c !.�. /✓ f-� : btu / 1/ 1 6) 14t'. . Address:/��a(a,� cT Q, Date: Account No. 2-0r-1 r'Lot(s Tract 2 t l Service Address U j = q (�� L•*•i -,•r G G.A. Code ❑ Meter(s)" $ ❑ Service(s) ❑ Backflow(s) ❑ House Lateral(s) ❑ Detector Check(s) ❑ Meter Surcharge Sanitation Capacity Charge ) 1 J ❑ W.S.B.F.C. ❑ S.I.W.S.C. ❑ Temporary Construction Meter ❑ Turn on Charge ❑ Uncollected Account - Name x ❑ Inspection Fee - Tract - Fee - ❑ Plan Check Fees Water / Sewer - i Tract -. ❑ Bond Payment - A.O. - Bond Assmt i1 ❑ Customer Deposit r ❑ Other TOTAL Remarks: ) —XCopy to: Cash C , . Water Service heck Money Order r� Cashier t .. ..... _ _ .. _ ." ._,.r .. CVWD-438 (1/05) • 1 r i