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12-0864 (BLCK)P.O. BOX 1504 --------- - -- - ------ -- - - - - -- - - - --— WORKER'S COMPENSATION DECLARATION ' 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: 12 00 00864'' Property Address: 54-785 P;VENfiDA RAMIREZ APN: 774-295-014-2 -000000- Application description: WALL/FENCE Property Zoning: COVE RESIDENTIAL Application valuation: 1342 Applicant: Architect or Engineer: BUILDING &SAFETY DEPARTMENT 'BUILDING PERMIT Owner: GUNNAR JORGANSON 54785 AVENIDA RAMIREZ LA QUINTA, CA 92253 Contractor:' CASTLE. CONSTRUCTION 68670 LOS GATOS CATHEDRAL CITY, CA (760)272-4191 -. - Lic. No.: 675800' VOICE (760) 777-7012' FAX (760) 777-7011 INSPECTIONS (760) 777-7153 4 AUG. 0.2 2012 CITY OF,LA QUINTA _FIN.4!14CF DFPT- Date: 8/02/12 v----- - --- -- --- -- --- ----- ' ICENS NTRACTOR'S DECLARATION - --------- - -- - ------ -- - - - - -- - - - --— WORKER'S COMPENSATION DECLARATION ' I hereby affirm under penalty of perjury that l" is d under pro ions of Chapter (commencing with I hereby affirm under penalty of perjury. one of the following'declarations -- - Section 70001 -of Division 3 of III Businas nd ssionals C 'and my License is in full force and effect. I have and will maintain.a certificate of consent.to self -insure for workers' compensation, as. provided Lic `se Class: B r - L" a o.r 675800 • - _ the. for by Section 3700 of the Labor Code, for the performance of the.work for which this permit is issued t DDaatter: ontractor: `r`. I have and will maintain workers compensation insurance, as required. by Section 3700 of the Labor / _.. Code for the performance of-thework for which this permit is issued- My workers' compensation - - -- NER=BUILDER DECLARATION;., • insurance carrier and policy number are: - » I hereby affirm unoer penalty of p ^'cKt6aLFexempt�from°tlie Contractor's'State License Law for the ,•� Carrier INCLD/STrFUND '-` ' " P is umtier :1863381-2012 . . following. reason (Sec.. 7031.57, Business and Profession Any city, 07 county that, requires a permit to _ I certrfythat, in the performan rk for which this permit,is issued;4 shall not employ any ' rCoder "construct, alter, improve, demolish; or repair any structure','. prior to its issuance, also requires the applicant for the Z% person in any manner so.. to ne a subject to the workers' compensation + laws of California, permit to file a s(gned'statement.that he;or..she islicensed pursuant.to the, provisions of the Contractor's State and agree that, if I should be subject.to the workers' compensation provisions of Section.. -;License Law (Chapter T(commencing with Section 7000) of Division: 3 of the Business and Professions Code) or 3700 of the Labor CoQ I .forthwith comply with those provisions. `that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by u1•�� any applicant for a permit subjects the applicant to a'ciyil pehalty of not more than five hundred dollars IS5001.: ate:ypplicant: 1 1, as owner the property, or my,employees with wages as their sole, compensation, will do the work, and _) ' the structureis not intended ar,offerad for sale (Sec. 7044;, Business and Professions.Code:. The WARNING:. FAIL RE TO SECURE�WORKERS'•COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL Contractors' State License Law�does notapply,to anrownei of property who builds or•improJes thereon, SUBJECT AN EMPLOYER TO. CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND and who does•'the-work himself herself through his or herowrremployees, prowded:.that the .DOLLARS ($100;0001• IN ADDITION TO THE COSTOF COMPENSATION, DAMAGES AS PROVIDED FOR IN improvements are'not intended. or offered for sale. If, however, the'building orimprovement is sold within SECTION 3706,OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. • oneyea(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.). APPLICANT. ACKNOWLEDGEMENT (_ 1 I, as owner of'the property, am: exclusively contracting with licensed contractors to construct the project (Sec. IMPORTANT Application is hereby made to the Director of,Building and.Sefety for a permit subject to the 7044, Business and Professions Code: The Contractors' State License Law does notapply to•an owner of conditions and restrictions set forth on this application. property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed 1. Each person upon whose behalf.this application is made, each person at whose request and for pursuant to the Contractors' State License Law.). whose benefit work is..performed under or pursuant to`any permit issued as a result of this application, (_) .I am exempt under Sec. , B.&P.C. forthis reason - 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 actor omission related to the work being performed under or following issuance of this. permit. Date: Owner: 2. Any permit issued as a result ofthis application becomes null and void if work is not commenced within 180 days from date otissuarice of such permit, or'cesset of work for 180 days will subject CONSTRUCTION LENDING AGENCY permit to cancellation. I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the isC. I certify that I have read this application and state that the abo is•correct. I agree to comply with all work for which this permit is issued (Sec- 3097, Civ. C.). city and county ordinances and stat6laws relating to building con n, authorize representatives of th county'to enter up o he above-mentioned property tion purposes. Lender's Name: 2 ate: g -nature (Applicant or Agentl: Lender's Address: LQPERMIT Application Number . . . . . 12-00000864 Permit . . . WALL/FENCE PERMIT Additional desc . Permit Fee . . . 33.00 Plan Check Fee.. .00 Issue Date . . . . Valuation 1342 Expiration Date 1/29/13 Qty Unit Charge Per Extension BASE FEE 15.00 9.00 2.0000 HND BLDG 50.1-2,000 18.00 ---------------------------------------------------------------------------- Special Notes and Comments' 62 L.F.'5' FRONT P/L.EINE GARDEN WALL, CITY STANDARD..201-0_CODES: _ . Fee summary - Charged Paid 'Credited Due ------.-------------------`---------------------- Permit Fee Total 33.00 .00, ---------- .00 33+.00 Plan Check Total .00 .00 .00, .00 ° Grand Total 33.00 00 :00 33.00. S _ LQPERMIT N1 121 CITY OF LA QUINTA BUILDING & SAFETY DEPT. APPROVED FOR CONSTRUCTION DATED a ABY :i N Cr' Bin # , Cray of La QWilb Building a Safety` Dunston P.O :Box: 1504,'78-495'Calfe Tamptcfl 1a.Qutnta, CA 92253 (760) 777-7012 Building ,Pe it Application and Tracking Sheet .. Permit# (�� . J I AV . vl t c� Project Address:1�`�: - YIcity'ST'Zi.- . Owns s Name:. 6-v:N�-h�� .. A. P. Number. Address:` . Legal Description: Contractor.. (�� c5 UIVSTYIIi 1 0 P. s. 'Telephone: M>.z� •.,ae�rr; Address: `"� } Q ProjectDescriptionc r, City, ST, Zip: Telephone: 7�0,' Rm MIR -� -State Lia #•: 6.7 51$06 city uc*. tE: Arch., Engr., Designer Address: City., ST, Zip: Telephone: State Lie. #: r , .?, Name of Contact Per' on:"..,Sq. : Gonstrudion T e yp • . Occupancy: ;project type (circle one):: New ' Add'n Alter Repair Demo FL: # Stories:.. #Unita: Telephone # of Contact Person: Estimated Value of Project: APPLICANT DO:NOT• WRITE BELOW THIS; UNE # Submittal Req'd Re Id :. TRACKIIYG PERMITFEFS Plan Stu Rlan Check submitted Item Amount Structural Calcs ,... ' Reviewed; ready for,coreections Plan Check Deposit. . Truss Cates. .. Called Coutaet Person Plan Check Balance. Title 24 Cates Plans picked up Construction Flood plain plan tPlans resubmitted.. Mechanical Grading plan Z°' Re61ew,•ready for correctionskssue -Electrical Subcontactor List Called Contact Person f Plumbing Grant Deed Plans picked up L ML H.O.A. Approval f :Plans resubmitted Grading UV ROUSE:-. Review; ready_ for corrections/issue Developer.Impact Fee Planning Approve Called Contact Person.. &LP.P. Pub. Wks. Appr Date of permit issues- School Fees . # Total Permit Fees .