04-4236 (TT)IJUILDING-& JAFETY DEPARTMENT
P.O. Box .1504 (760).777=701.2
78-495 CALLS TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTION REQUESTS (760) 777-7153
BUILDING PERMIT
Application Number . . .
04-00004236
Date." 5/28/04
..Property -Address . . . .
57360 PENINSULA LN
APN:
762-150-003- - -
Application descriptiori . '',,TEMPORARY.
TRAILER
Property Zoning . . . .
LOW.DENSITY RESIDENTIAL
,..Application valuation
.20000.
='Owner.
Contractor
BELLA OCEANA LTD PARTNERSHIP
JACOBS HOMES INC,
PETER
1354 BELLA. OCEANA VISTA
P.O.. BOX' 692 .
PACIFIC..PALLSADES.. :. CA .9.0272.:
LA. QUINTA
CA 92253.
777 9921-
921
,(760)
WCC::. EXEMPT.
WCC.::.
WC: EXEMPT
04/30/05
CSLB:` 799499
04/3'0/05
CCC: B
-------------
Permit TEMP TRAILER / MOBILE HOME
Additional-desc .
Permit Fee 200.00
Plan Check Fee'
.00
Issue Date . . . .
Valuation . .
. . 20000
Qty.. Unit. Charge: Per
Extension
BASE FEE
200.00
Special Notes and Comments.
Sales Office Modular Trailer:.`MUP
2004-480
Fee summary Charged.
Paid Credited
'Due
Permit Fee .Total. 200.00
.00. .:00 `
200`.00
Plan Check Total .00
.00 .00
.00.
Grand Total 204..00.
..00' .00
200.00
CITY ®�t�5�q Lk ONWTA
07PT
P.O. 'Box 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
Application Number: 0.4 '12 3,6
Applicant:
Applicant's Mailing Mailing Address:
Architect or Engineer:
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date:
Architect or Engineer's Address:
Lic. No.:
BUILDING PERMIT DECLARATIONS
UCENSED'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 lac,Ase is in full force and effect. �p 9 y99
License Class) Z3 License No.
• i
Data 1 S•� o y Contractor7��C0$ S
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 Ihat 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 the or she did not build'or improve for the purpose of sale.).
(, 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 1 am exempt under Sec. , BA P.C. for this reason
Date Owner
I hereby affirm under penaltyof WORKERS' COMPENSATION DECLARATION
perjury one of the following declarations: .
_ I have and will maintain a certificate of consent to self4nsure 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 mer and policy number are:
Cartier Policy Num r 1 certify that, in the performance ofthe work for i this permit is Issued, I shall not7'�/
y any person in any manner so.as to become subject to the workers'
compensation laws of Cal'rfomia, and ag tatI should become subject to s' compensation provisions of Section 3700 of the labor Code, I shall
forthwith comply with those provisions. , �_
'Date S d o 0 � Applicant
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVE GE IS
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), I
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
AWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
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
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 actor omission related to the ork being performed under or following issuance of this permit
2. Any permit issued as a result of this application becomes null and d 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 e rectId comply with 11 city and county ordinances and state laws relating to building
construction, and hereby authorize representatives of this county to enter u - n n ned profor inspection purposes.
41
bate �- 7 _ Signature (Applicant or Agent): _
y