06-2369 (BLCK)P.O. BOX 1504
78-495 CALLS TAMPICO
LA-QUINTA, CALIFORNIA 92253,
Application Number: l 06-00_002369
Property Address: tt�� 57210 PENINSULA LN
APN: 762-150-021-
Application
62-150-021 Application description: WALL/FENCE
Property Zoning: LOW DENSITY RESIDENTIAL
Application valuation: 3550
Tityl 4 4Q*tw
Applicant: Architect or Engineer:
BUILDING &. SAFETY DEPARTMENT
BUILDING PERMIT
U�.
' LICENSED CONTRACTOR'S DECLARATION
hereby affirm under penalty of perjury that I am licensed 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 Class: C29 License No.: 649905
Dater -Contractor: -
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's 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 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 05001.:
(_ I 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 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 willhave the burden of proving that he or she did not build or
improve for the purpose of sale.).
1 _ 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 theewho contracts for the projects with a contractor(s) licensed
pursuant to the Contractors' State License aw.).
(_) I am exempt under Sec. , B.&P.C. r 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:
LQPERMIT
VOICE (760) 777-7012
FAX (760) 777-7011 ..
INSPECTIONS (760) 777-7153
Dater
Owner:
SOUTHERN HILLS DEVELOPMENT
78150 CALLE TAMPICO
LA_ QUINTA, CA 92253FAUN
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Contractor: 14 2006
SA13OR MASONRY41625 ECLECTIC STRELA000NTA
PALM DESERT, CA 922CE DEPT.
(760)674-0666
Lic. No.: 649905
6/13/06
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WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations: r _
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 STATE FUND Aof
Number 0016140-2006
_ I certify that, in the perfork for which this permit is issued, I shall not employ any
person in any manner subject to rkers' compensation laws of California, -
and agree that, if I shost to the orkers ompensation provisions of Section
3700 of the Labor CoW se provisions.
Date: L6pplicant:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION VERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (5100,000). 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 11 and void if work is not commenced
within 180 days from date of issuance of such permit, cessation of work for 180 days will subject
permit to cancellation.
I certify that I have read this application and state that the above o,mation is c rect. I a ree to comply with all
city and county ordinances and state laws relating to building ction, and orize representatives
of this c my t:/�eintt upon the above-mentioned property f in e i ur e '
Date: yyea/ V"Signature (Applicant or Agent):
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Application Number 06-00002369
Permit WALL/FENCE PERMIT
Additional desc .
Permit Fee . . . . 63.00
Plan Check
Fee
.00
Issue.Date.
Valuation
3550 .
Expiration Date 12•/10/06
Qty Unit Charge Per
Extension
BASE FEE
45.00
2.00 9,0000 THOU BLDG 2,001-25,000
18.00
Special Notes and Comments
142 L.F. 6' GARDEN WALL,,ORCO SYSTEM
Fee summary Charged Paid
Credited
Due
Permit -Fee Total 63.00.
.00
.00
63.00
Plan Check Total .00
.00
.00
.00
Grand Total 63.00
.00
.00
63.00
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