05-1802 (PLBG)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: . O:S•= 0,0AA:1802
Property Address: 52711 AVENIDA RUBIO
APN- 773-282-023-10 -000000-
Application description: PLUMBING
Property Zoning: COVE RESIDENTIAL
Application valuation: 0
T,• 4 4 "
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Applicant: Architect or Engineer:
' NI
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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,Codejand my License is in full force and effect.
License,Class: C34 r /-- is s No.: '529319
Date Con g or., 4'z, rP_�_..
OWNER -BUILDER DECLARATION '
I hereby affirm underr-penalty of perjury that I am ezemptirom the Contractor's'State-License Law for the
following reason�ISec. 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,kensed pursuant to theprovisions of the:Contractor's State
License Law (Chapter 9 (commencing with: Section 7000) of'Division 3 of the. Business arid.Professions Code) or
that he or she is exempt therefrom and the basis for the alleged exemption. -Any violation of Section 7031.5'by
anyapplicant fora permit subjects the applicant to a civil penalty:of not more than five hundred, dollars;($500).:
1 _ 1 1, as owner of theproperty, or my employees with wages as their sole compensation, will do the work, and
the:strutxure isnot 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 or improves thereon,
and'who does the.work himself'!oi�herself through his other own employees, provided that the
improvements are not intended'oroffered 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 ofsale.).
(_ 1 I, as owner of the property,am exclusively contracting�witli 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.).
(_) 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 ( ecA97, Civ. C.).
Lender's Name: It
Lender's Address:
LQPERMIT
Owner:
GARNENS, ALEX
52711 AVENIDA RUBIO
LA QUINTA, CA 92253
Contractor:
WILSON BACKHOE, B
P O BOX 1687•
INDIO, CP;- 92201
(760-)347-6946
Lic.-No.: 529319
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 5/11/05
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 tw
he ork foi`which this permit'is
issued: a , .. .. _ ,
_ I,have and wilJ 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 STATE. FUND Policy Number 00022922197
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
3700 of,the Labor e; I shall forthwith co ply wit W ose provisions.
Da_t"- Applican - -
WARNING: FAILURE TO SECURE WORKERS' COMPENSATIO-OVERAGE-IS' NLAWFUL;.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 'Applicaiion:is hereby.made to the Director.of Building and Safety for a permit subject to the
conditions and restrictions setforth 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 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 out r ze representatives
of this county to enter upon the above-mentioned proMrRyppfor inspection purpose.
Dater Signature-IApppplicantlo?'Agent):mr'�'l.0-I ��
r'
Application Number . . . . . 05-00001802
Permit . . . PLUMBING SEWER
Additional desc .
Permit-Fee . . . . 30.00
Plan Check
Fee
.00
Issue Date . . . .
Valuation
. . .
. 0
Expiration Date 11/07/05
Qty Unit Charge Per _
Extension
BASE FEE
30.00
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Special Note's.and•Comments
------------------
SEWER CONNECT/SEPTIC. ABAND.ONEMENT-.
_
Fee summary iCharged Paid
Credited
Due
--------------------
Permit Fee Total 30,;00
----------
:00
------
.00
30: 0.0
Plan 'Check Total 0.0
:`OD
00-
.'00
Grand Total 30.0.0
00
.00
30.00
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