0211-003 (COMM)LICENSED CONTRACTOR 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 # Lic. Class Exp. Date
813480 B BIC
Date Signature of Contractor
OWNER -BUILDER DECLARATION
10/31 /0Z
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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. 7.044, Business ,& Professionals Code),
( ) I, as owner; of -the property, am .exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals.
Code).
() I am exempt under Section B&P.C. for this reason
Date, Signature of Owner
WORKER'S' COMPENSATION DECLARATION
I hereby. affirm under penalty .of perjury one of ,the"_,following-declarations:
O thave and will maintaima certificate`of.conseni to self -insure for workers'.
compensation, as 'provide'd for';by, Section. 3700 of the Labor Code, for the
performance of the work for which this permit• is issued.
O 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 & policy no., are:
Carrier
Policy No:
ZURICKAMERICAN WC298892003
(This section need not be.00rnpieted if the permit;valuation'is for $100.00 or less).
O (°certify that in the performance oithe 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 3700 of the Labor
Code, I shall forthwith comply. with those provisions.;
Date:. Applicant
Warning "Failure to secure•Workers'"Compensation coverage is•unlawful and
shall. subject an employer to criminal penalties and civil fines up to $100;000, in
addition.to the cost of compensation' damages as provided for Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a- permit subject to the 'conditions .and restrictions set forth on his
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 applicaton agrees to, & shall, indemnify
& hold harmless the City°of La Quinta, its officers, agents and employees.
2. Any permit issued asa result of this application becomes null and void if
work is not commencedwithin 180 days from date of issuance of such
permit, or cessation of work for 180 days mill subject permit to cancellation.
certify that I have read this Application and -state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this -City to enter upon
the above=mentioned property. for inspection purposes.
Signature (Owner/Agent) Date
P11 y
BUILDING PERMIT PERMITk
—
DATE VALUATION LOT 0211-003
TRACT
$383,910.80 45
30096-1
JOB SITE
ADDRESS
APN
57-325 PASEO DEL LAGO
726-240-003
OWNER
CONTRACTOR/ DESIGNER / EN INEER
PUERTA AZUL PARTNERS LLC
DAVIS REED
17700.9,W, UPPER BOONES FERRY RD.
169 SAXONY ROAD, STE. 105
PORTLAND OR 97224
ENCIIJTTAS
CA 92024
(760)634-2350
CBL# 420
USE OF PERMIT
CONflV RCIAL
COMM - 5305 SQ. FT. REC, BLDG PUERTA AZUL -SUB DIVISION TRACT
30096. A. /R3/SUUI.00C. TYPE V-1HRCONSTR. PERMIT* DOES NOT.
INCLUDE BLOCK WALLS, POOL -OR -SPA.
TRACT CONSTRUCTION 924.00 SF
PORCH/PATIO. 3;282.00 'SF
GARAGE/CARPORT 544.00 SF
SPRINKLER,`,' 5,305:00 5F
AJC --.RESIDENTIAL 924,00 SF
A/C -- COMMERCIAL 3,268.00 SF
ESTIMATED COST OF CONSTRUCTION-
383,910.80
PERMIT FEE SUAUAARY
CONSTRUCTION FEE 101-000-418.000 $I,b33.S0
PLAN CHECK FEE 101-000-439-.318 $11659:44
FEE DEPOSIT 101,-000-439.318 -$1,659.44
MECHANICAL FEE 101=000-421-000 $161.00'
ELECTRICAL FEE 101-Q00.420-000 $207.06
;PLUMBING FEE 101-000-41 9-.000 $279:00
STRONG -MOTION FEE - COMM 100-000.241.000 $80.62
DEVELOPER IMPACT FEE. $10,615.00
ART -IN PUBLIC PLACES - COMP 270.000-445.000 $1,919:55
SUB -TOTAL CONSTRUCTION AND -PLAN CHECK
$16,555.17
LESS PRE -PAID FEES
-$1,659.44
TOTAL PERNM FEES DUE NOW
$14,895.73
s
=ot�.Planch�eck �4eand deposit amount re
lect additionz
$329.72 for unpaid balance due on previously
expired appli(
RECEIPT DATE BY DATE FINALED INSPECTOR