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05-5209 (TT)P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 c&h-t 4 44urKrw BUILDING & SAFETY DEPARTMENT BUILDING PERMIT Application Number: 05-00005209 Property Address: 57370 PENINSULA LN APN: 762-150-002- - - Application description: TEMPORARY' TRAILER Property Zoning: LOW DENSITY RESIDENTIAL Application valuation: 450 D(CjITY Applicant:Architect or Engineer:2005 F LA QUINTA bd p _PT. LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that I am licensed u der provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busine and Professi Ide, and my License is in full force and effect. Licenseff CI ss: B c se No.: 838041 ate: 1 - ntractor: OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that am exempt from 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 licensed pursuant to the provisions of the Contractor's 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 1$5001.: (_ 1 I, 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 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.). ' (_ 1 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.). 1 _ 1 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 ISec. 3097, Civ. C.). Lender's Name: Lender's Address: LQPERMIT VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 11/29/05 Owner: FULLER WILLIAM P.O. BOX 504'0 LA QUINTA, CA 92253 Contractor: SOUTHERN HILLS DEVELOPMENT INC 78150 CALLE TAMPICO STE 101 LA QUINTA, CA 92253 (760)771-3497 Lic. No.: 838041 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 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: Carrier EXEMPT Policy Number EXEMPT I c=at, 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 subjec to the workers' compensation provisions of Section 700 of the Labor Code, I stall f wi ply with those provisions. �6ate: A cant: WARN G: FAIL RECU TO RE W K RS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJE TAN EMPLOYER TO CRIMINA ENALTIES 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 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 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 relatin to building cos ruction, and hereby authorize representatives of this co my to enter upon the ab mentione pope for ' e ion purposes. D e: , Si :u -re (Applicant o en Application Number . . . . . 05-00005209 Permit. . . . TEMP TRAILER / MOBILE HOME Additional desc . Permit Fee . . . . 200.00 Plan Check Fee .00 Issue Date Valuation . . . . 450 Expiration Date 5/28/06 Qty Unit Charge Per Extension BASE FEE 200.00 ---------------------------------------------------------------------------- Special Notes and Comments TEMP. CONSTRUCTION TRAILER PER MUP #2005-703 Fee summary ----------------- Charged Paid -------------------- Credited -------------------- Due. Permit Fee Total 200.00 .00 .00 200.00 Plan Check Total .00 .00 .00 .00 Grand Total 200.00 .00. .00 200.00 •LQPERMIT saa3;lwaad leio.L saag loops anssi ilwjad io ale( addV •s)iM •qnd 'd'dTV u0slad;aeiu00 pape0 lenoaddV 2uluueld aag iaedwl aadoiaeaQ anssysuol;333103 .aqi ,Cpea.a °etalnag P+C - dSIIOH All 2ulpeaO pa;;!wgnsaa Sueld lenoaddV •V•0•g 'I IN.s do payaid sueld paaQ;ueaO 2ulgwnld uosaad;ae;uo0 pape0 ;slZ aoiaeiuoagns ieau;said anss!/Suoliaa»oa aoi ,(peal 1e01e3g p„Z ueid 2wpej0 iealueyaaN pa;ilwgnsal sueld ueld meid poo13 u0li3na1suo0 do paiia!d sueld sais0 f�aaug aauelug iiaa40 Ueld uos.aad iaeiuo0 PalleO s31e0 ssn.il, ;!soda(piaa40 ueld suol)331103 lo3 ,(peal 'paetalnagsae e.tn ana ' 1 01 i 35 ;unowV wall paiilwgns pay0 Ueld Sias ueld saga1INiudd DNHNDVHL P134H P,bau leia!wgnS # 3NI1 SIH! 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