06-3298 (BLCK)V
A
P.O. BOX 1504. VOICE (760) 777-7012
78-495 CALLE TAMPICO FAX (760) 777-7011 .
LA QUINTA, CALIFORNIA 92253 BUILDING &, SAFETY DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING PERMIT
Application Number: 0.000'3'2-98
Property Address: 54780 AVENIDA RAMIREZ
APN: 774-301-0:03-22 -000000-
Application description: WALL/FENCE
Property Zoning: COVE RESIDENTIAL
Application valuation: 1550
Applicant: Architect or Engineer:
--------------------------
- • .LICENSED CONTRACTOR'S DECLARATION
I hereby affirmunder penalty.of,perjury that I anilicensed under provisions of Chapter (commencing with,
Section 7000) of Division 3 of the` Business. and Professionals Code, and-my.License is in full force and effect.
License Cl s:C10 C29. License No439904
Date ( <(L ®pContractor.
• OWNER-BUILDERDECLARATION�• i
I hereby affirm under penalty of perjury that I am exempt from tlie,Contractor's State License Law for the
following'eeasonl(Sec: 7031.5,,B6siness and Professions Code: -Any city or county that requiies,a permit to •.
constructs alter impioye,.demolish, or, repair any structure, prior'to its issuance, also requires the applicant for the
a
permit to file signed statement that he or sheds licensedpursuant.to the provisions of the Contractors State
.License Law (Chapter 9 (commencing with Section 7000)-ofDivision.3'-of the Business and Professions Code) or
that he.or she is exem Ytherefrom and the basis f r h II x m i Any v 1 i
p s o the a egeo;e e_ pt on A y w anon of Section 7031.5 by
any applicant for a• -permit subjects the applicant to a civil penalty of not more` than five hundred dollars ($500).:
(_ 1 .I, as owner of the property, or my employees with wages as their solercompensation, will do the work, and
the structure isnot intended or offered for.sale (Sec. 7044, Business and Professions Code: The
Contractors' State License Law does not apply.to an owner of property who -;builds or improves thereon,
and who does the work himself'or, herself through his or he(own employees; provided that the
improvements arenotintended or offered for sale. If, however, the building or improvement is sold within
one year"of completion,the owner -builder- will have the burden of provinif ilhethe;or she did not build of '
improve for the purpose of sale.).
1 _ 1 .1, as owner of the property, am' exclusively contracting with licensed contractors to construct the project (Sec.
7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of
property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed
pursuant to the Contractors' State License Law.).
(_) I am exempt under Sec. , B.&P.C. for this reason
Date:
Owner:
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the
work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name: _
Lender's Address:
LQPERMTT
------------------------------_------------ -- -
WORKER'S COMP,ENSATIOWDECLARATION- =
I hereby affirm underpenalty'of perjury onelof the'.following declarations: _ -
I have and;will'mainfain;a certificateof.'consent to self -insure for workers' compensation, as provided
-'for by„$ection 3700 of the Labor Code, for the performancei'of the work for which this permit is
issuedf - •.
I have and,will maintain workers' compensation insurance; as required by Section 3700 of -the Labor
de.'
Co`foi�the performance of the work for which this permit is issued,' My workers' compensation
•.��r insurance'carrier and 'policy -number are: -
Calrier,STATE",FUND, Policy Number 1641435
_ I certrfy.Niat,-in the,performance"ofthe,work for which this permit•isissued,a shall.not employ any
person,in any manner so as to'oecome subject to the workers"compensation laws of•California,
and agree that, if �Ishouldb me subject to the workers' compensation provisions of Section
3700 of the Labool'fort ith those provisions.
fA
fCate-'?'� .6 Applicant:
WARNING: W
FAILURE TO SECURE'OFi ERS' COMPENSATION COVERAGE IS UNLAWFUL, -AND SHALL
SUBJECT,AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS''($l00,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES -AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. '
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby:made to the Director of Building and Safety for a permit.subject to the
.conditions and restrictions set forth on this•application. '
1. Each person upon whose behalf this application is made, each person at whose request and for
whose benefit work is performed under or pursuant to any permit issued'as a result of this application,
the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City
of La Quinta, its officers, agents and employees for any act or omission related to the work being
performed under or following issuance of this permit.
2. Any permit issued as a result of this application becomes null and void if work is not commenced
within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject
permit to cancellation.
I certify that 1 have read this application and state that the above information is correct. I agree to comply with all
city and county ordinancesandstate laws relating to building cWstruction, and hereby authorize representatives
of this coun t enter upon the above-mentioned property rre
pDa
'Y( (Sig -Applicantnature" or gent):
D �—
Date: 9/11/06
Owner:
JEAN ROUNSVILLE
54780 AVENIDA RAMIREZ
LA QUINTA, CA 92253
Contractor:
STRZELCZK, EDWARD J.
D d
83420 SHADOW HILLS WAY
INDIO, CA .92203
(760) 347-0399
SE 1
1
LiC. No.: 439904'
CITYOP•f
------------------------------_------------ -- -
WORKER'S COMP,ENSATIOWDECLARATION- =
I hereby affirm underpenalty'of perjury onelof the'.following declarations: _ -
I have and;will'mainfain;a certificateof.'consent to self -insure for workers' compensation, as provided
-'for by„$ection 3700 of the Labor Code, for the performancei'of the work for which this permit is
issuedf - •.
I have and,will maintain workers' compensation insurance; as required by Section 3700 of -the Labor
de.'
Co`foi�the performance of the work for which this permit is issued,' My workers' compensation
•.��r insurance'carrier and 'policy -number are: -
Calrier,STATE",FUND, Policy Number 1641435
_ I certrfy.Niat,-in the,performance"ofthe,work for which this permit•isissued,a shall.not employ any
person,in any manner so as to'oecome subject to the workers"compensation laws of•California,
and agree that, if �Ishouldb me subject to the workers' compensation provisions of Section
3700 of the Labool'fort ith those provisions.
fA
fCate-'?'� .6 Applicant:
WARNING: W
FAILURE TO SECURE'OFi ERS' COMPENSATION COVERAGE IS UNLAWFUL, -AND SHALL
SUBJECT,AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS''($l00,000). 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 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 1 have read this application and state that the above information is correct. I agree to comply with all
city and county ordinancesandstate laws relating to building cWstruction, and hereby authorize representatives
of this coun t enter upon the above-mentioned property rre
pDa
'Y( (Sig -Applicantnature" or gent):
D �—
d
LQPERMIT
Application Number . . . . . 06-00003298
Permit. . . . . . WALL/FENCE
PERMIT INV FEE
Additional desc .
Permit Fee . . . . 74.00
Plan Check
Fee
.00
Issue Date . . . .
Valuation
. . .
. 1550
Expiration Date . . 3/10/07
Qty ' Unit Charge Per
Extension
BASE
FEE
30.00
11.00 4.0000 HND BLDG
501-2,000
44.00
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Special Notes and Comments
62 LF COMBO 2' RETAINING WITH 6'
GARDEN
WALL PER CITY STANDARD.
Fee summary Charged
-
Paid Credited
Due
- -------- - - - - - ----------------------
Permit.Fee Total 74.00
----------
.00
----------
.00
74.00
Plan Check Total .00
.00
.00
.00
Grand Total 74.00
.00
.00
74.00
Bin #
City of La ,Qu•inta
Building, 8L Safety Division
PO .Boz 1504, 7l.8-495`.Calle Tampico
La Qulnta, CA:.92253 - (T60) 777=7012
Building Permia'.A0011cation -.and Tracking Sheet
Permit #
Project Address:
Owner's Name:
A. P. Number:
Address: J' _ D
Legal Description:
Contractor: �� �.. ' Z z
City, ST, Zip:
Telephone:
Address:g f
-Project Description:
G
City, ST, Zip;
Telephone:
State Lic. #:. City Lic. #:
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone:
State Lic. #:
Name of Contact Person:
Construction Type: Occupancy:
'Project type (circle on New Add'n Alter Repair Demo
Sq. Ft.i
#Stories:
#Units:
Telephone # of Contact PeiPn:
Estimated Value of Project:
APPLICANT:._DO.NOT WRITE.BELO.W.THIS LINE,
V
Submittal.
"Req'd
Recd.
' ' TRACIONG _
PERMIT FEES
Plan Sets
Plan Check submitted'
Item
Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit,
Truss Calcs.
Called Contact Person '
Plan Check Balance
Energy Calcs.
Plans picked.up
Construction
Flood plain. plan
Plans resubmitted
Mechanical
Grading plan
201 Review, ready for correctiorisrssue
Electrical
Subcontactor. List
'Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted .
Grading
IN HOUSE:-
Review, ready for correctioriVissue
Developer Impact Fee .
Planning Approval
Called Contact Person ,...
A.LP.F.
Pub. Wks. Appr ;
Date of perm it`issue
.School Fees
Total Permit Fees