04-4552 (BLCK)Jill
°� MAY 2 6 2004.
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9 iAi�111NTA BUILDING& SAFETY DEPARTMENT
9th+ xiS T
(760)777-7012
OF T1 78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 922.53 INSPECTION REQUESTS (760) 777-7153
BUILDING PERMIT
Application Numberr04-00004552
? Date
5/25/04
Property Address
~7-940_5_HIGHWAY 111.
APN::.
649-030-999-6 -30420 -
Application description
WALL/FENCE
Property Zoning . . . . .
REGIONAL COMMERCIAL.
Application valuation'.
1575
Owner.
Contractor
STAMKO DEV CO
JACOBSSON ENGINEERING
CONSTR
C/O PROVIDENT.FINANCIAL MGMT
P.O. BOX .14430
10345 W OLYMPIC BLVD'2 FL
PALM DESERT.
CA 92255
LOS. ANGELES CA 90064
WCC: HRH INS
WC: 157666103
10/01/04
CSLB: 650389
07/31/04
CCC: A -B
------------------
Permit . . . . . . WALL/FENCE.PERMIT
Additional. desc
Permit.Fee 37.00 Plan Check Fee ,.
00
Issue Date
Valuation
1575
Qty. Unit Charge Per
Extension
BASE FEE
15.00-
'11.0.0. 2.0000 HND .. . BLDG 501'-2, 000
22.00
Special Notes and Comments
----------------------------
"
63LF-6' BLOCK -WALL PER ORCO DETAIL TO
FORM TRASH ENCLOSURE PER CDD APPROVED
PLAN. 2001'CBC.
Fee summary Charged
..Paid Credited' Due
Permit Fee total 37.00
:00 .00
37.00
Plan Check Total .00
.00. ..0.0
.00
Grand Total 37.00
.00 .00
37.00
r
P.O. BOX 1504 �
78-495 CALLS TAMPICO VOICE (760) 777-7012
LA QUINTA, CALIFORNIA 92253 ' FAX (760) 777-7011
INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number:—'5���2—_
Applicant:
Applicant's Mailing Address:
Date:
Architect,or
Architect or Engineer's Address:
Lic.. No..
QV1L-UIIVv rr-KMI1 utULAKATIONS
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
CodLmense Class Lice is in fullforce and effect 4_
�/ /-� � Li ^ No. r
GDa"te, a s V Contra
ly
OWNER -BUILDER DECLARATIOV
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 ft 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-exempt4herefrom-and-the-basi's-for-ft-slleged-exempbon-AnyMoWW—n of'Sectii�031. y 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 oftered 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 selfinsure 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:
Cartier /"tf /+- Policy Number / X66 /0 ^�
_ I certify that .in the performance of the work for which this permit is issued, I shall not' ploy 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, 1 shall
forthwith comply with those provisions.
Date s Q ApplipnI '
y
WARNING: FAILURE TO SECURE WORKERS'CC6PENSATION 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.
I herebyaffirm urider CONSTRUCTION LENDING AGENCY
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
IMPORTANT Application is hereby made to the Director of BuildingAPPLICANT Sa Safety aCKNOWL.EDGEMENT
I. A Each tY permit subject to the conditions and restrictions set forth on this application.
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, indemnity 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 penrit 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 information is correct. I agree to comply with all city and. county ordinances and state laws relating to building
construction. and hereby authorize representatives of this county to enter up% , above-mentioned property for inson purposes.
Date✓ n� U Signature'(Applicant or Agent):
vm 0