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04-5345 (RER)BUILDING & SAFETY DEPARTMENT P.O. Box 1504 (760).777-7012 78-495 CALLE TAMPICO FAX (760) 777-7011 LA QUINTA, CALIFORNIA 92253 INSPECTION REQUESTS (760) 777-7153. BUILDING PERMIT .y . Application Number . . . . . 04-00005345 Date 8/05/04 Property Address . . . . . . 57875 BLACK DIAMOND APN: 762-370-010- - Application description . . . REMODEL - RESIDENTIAbL N Property Zoning . . . . . . . LOW DENSITY RESIDENTIAL- Application ESIDENTIAL Application valuation . . . . 5000 Olr U ( UINTA LLM;1 Owner ContractorANCEDEPT. - - - - - - - - - - - - - 7- - - - -•- _ - .. P, ;f� - - -t< -,- t -. - -.- -.- - - - - - - - - - - - - . SOUTHERN HILLS DEVELOPMENT SOUTHERN HILLS DEVELOPMENT INC 55161 SOUTHERN HILLS 81070 CHANTICLEER DR LA QUINTA CA 92253 LA QUINTA CA 92253 (760) 771-3497 WCC: EXEMPT WC: EXEMPT 05/31/05 CSLB: 838041 05/31/06 CCC: B . ------ Structure Information FREESTANDING FIREPLACE & LATTICE PATIO ----- Construction Type . . . . . TYPE V - NON RATED Other struct info . . . CODE EDITION 2001 ---------------------------------------------------------------------------- Permit . . BUILDING PERMIT Additional desc Permit Fee . . . . 54.00 Plan Check Fee 35.10 Issue Date . . . . Valuation . . . . 2500 Qty Unit Charge Per Extension BASE FEE 45.00 1,. 00.•<. 9..0,000 THOU BLDG 2,001-25,000 9.00 -----------------------------------------------------7---------------------- Permit . . . . . PLUMBING Additional desc Permit Fee . . . . 18.00 Plan Check Fee 4.50 Issue Date . . . . Valuation 0 Qty Unit Charge Per Extension BASE FEE 15.00 1.00 3.0000 EA PLB GAS PIPE 1-4 OUTLETS 3.00 ---------------------------------------------------------------------------- Special Notes and Comments Freestanding Fireplace & Freestanding Lattice Patio Cover 215 sqft. ----7---------------7------------------------------------------------------- Other Fees . . . . . . . ENERGY REVIEW FEE 3.51 P.O. Box 1504 Tdy VOICE (760) 777-7012 78-495 CALLS TAMPICO FAX (760) 777-7011 LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153 BUILDING & SAFETY DEPARTMENT Application Number: :534 S Date: g Applicant: Applicant's Mailing Address: C7 Architect or Engineer: Architect or Engineer's Address: Lic. No.: BUILDING PERMIT DECLARATIONS 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 Code, and my Lice n is in full force and effect.Q Qb / License Class ) License No. e Q / y- 3( b l✓FFG >�f Gds �J>.� �� Dat9 � 0 'Contractor OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractors' 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 Contractors' 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).): U 1, 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 or 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.). U 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.). U I am exempt under Sec. , BA P.C. for this reason Date Owner WORKERS' COMPENSATIONDECLARATION 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. 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 and policy number are: Cartier Policy Number 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 bor Code, I shall forthwith comply with those provisions. 6X,eV 'Date R-6—'24/Applicant WARNING: FAILURE TO SECUR ORKERS' COMPENSATION COVERAGE IS UNLAWFUL, 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. 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 Lenders Address 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 Ouinta, 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, 1 agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to enteru on the a e e -mentioned perty for inspection purposes. Date Sighature (Applicant or Agent . Page 2 Application Number . . . 04-00005345 Date 8/05/04 ---------------------------------------------------------------------------- Other Fees . . . . . . . . . STRONG MOTION (SMI) - RES .50 Fee summary ----------------- Charged ---------- Paid ---------- Credited ---------- Due ---------- Permit Fee Total 72.00 .00 .00 72.00 Plan Check Total 39.60 .00 .00 39.60 Other Fee Total 4:01 .00 .00 4.01 Grand Total 115.61 .00 .00 115.61 CITY OF LA QUINTA SUB -CONTRACTOR LI T JOB ADDRESS PERMIT NUMBER OWNER_ 1ZLf: k� e riftlif5 BUILDER sot This form shall be hosted on the job with the Building Inspection Gard at all conspicuous times in -a glace. Only persons appearing. on this list or their employees are authorised to work on this job. Any changes to this list must be approved by the Building Division prior to commencement of work Failure. to comply will result in a stoppage, of work and/or the voidance of building permit. For each.applicable trade, all information requested below must be completed by applicant. -l'On.File'.is not an acceptable :response. BONN,:<.. _g�,**' .rg.,E .: a�,�c4 'Ct'�^i, � ...,<' :..,,:$>,.>:`.,"'>„"'.�.:•��; :. �."� .k£'-:"�,`"S:w �":.,'�F'e�.''':£�S.w. OTrade��.Class►tf��t;.�o��.� a�f,�.�.Yes$'a'"?§"-�:;...::"'�4>�:�`..;...a.`'rYCK�`".k:."� ,`;<"4a,.k�.s'Z`S�J::•@»`">.:'=v Company Name Classi kation Ucerise Number Exp. Date Carrier Name Policy Number Exp. Date License Number Exp. Date c a:z a q� '.; '' ` Sy ° > ' (e.g. A, B, C -S) (xxxxxx) (xx/xx/xx) . N.g. 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