07-1462 (TT)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
Property Address:
APN:
Application description:
Property Zoning:
Application valuation:
07-00001462
79485 HIGHWAY 111
600 -020 -027 -
TEMPORARY TRAILER
REGIONAL COMMERCIAL
250
Applicant: Architect or Engineer:
------------------
LICENSED CONTRACTOR'S DECLARATION
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
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 CI s: A B C8 C27 License No.: 181805
.Date / Contractor: 01 '► _ __
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
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 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.). `
1 1 I am exempt under Sec. , B.&P.C. for this reason
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
Owner:
STAMKO DEV CO
10345 W OLYMPIC BLV 2 FL
LOS ANGELES, CA 90064
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (7 60) 777-7153
Date: 5/16/07
r1tM:AY
A
Contractor:
DIFFENBAUGH INC, J D �+76865 AIRPORT DRIVE 6 2007
RIVERSIDE, CA 92504
(951) 351-6865 CII OFL,gQ�JNTq
Lic. No.: 181805 FlRlewi%eft.�
---7-------------------------------------------
WORKER'S COMPENSATION DECLARATION
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.
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 AMER CASUALTY Policy Number WC274971872
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
r , 3700 of the Labor Cod shall forthwith comply with those provisions.
Date: J Applicant:✓
or
WARNING: AILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS 1$100,0001. 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 b s null and void if work is not commenced
within 180 days from date of issuance of such per i , or cessation of work for 180 days will subject
permit to cancellation.
I certify that I have read this application and state that the ormation is cor t. I agree to comply with all
city and county ordinances and state laws relating to buil ng r ction, and reby authorize representatives
ofthis cou y enter upon the above-mentioned prope f i tion pu ses.
Date: !Q&_Signature (Applicant or Agent):
Application Number . . . . . 07-00001462
Permit . . . . . . TEMP TRAILER
/ MOBILE HOME
Additional desc .
Permit Fee. 200.00
Plan Check
Fee
.00
Issue Date . . . .
Valuation
. . .
. 250
Expiration Date 11/12/07
Qty Unit Charge Per
Extension
BASE
FEE
200.00
----------------------------------------------------------------------------
Special Notes and Comments
TEMP. SECURITY TRAILER FOR NEW
CONSTRUCTION ON PARCEL 1
Fee summary Charged
Paid Credited
Due
Permit Fee Total 200.00
.00
.00
200.00
Plan Check Total .00
.00
.00
.00
Grand Total 200.00
.00
.00
200.00