0305-233 (SFD)LICENSED CONTRACTOR 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 License is in full force and effect.
License #Lic. Class Exp. Date
640934 B 6/30/03
Date Signature of Contractor .
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that 1 am exempt from the Contractor's
License Law for the following reason:
( ) 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 & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section , B&P.C. for this reason
Date Signature of Owner
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 & policy no. are:
Carrier NATIONAL UNION F. Policy No. 7085309
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) 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 Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $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.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
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 applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
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 State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon.
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT0305-233
DATE VALUATION $185,095.30 LOT 184 TRACT 30023
JOB SITE
ADDRESS 60-282 POINTSETTIA PLACE
APN 764-270-017
OWNER
CONTRACTOR / DESIGNER / EN (NEER
SHEA HOMES FOR ACTIVE ADULTS
SHEA HOMES
60-311 TRILOGY PARKWAY
81.260 AVENUE 62
LA QUINTA CA 92253
THERMAL CA 92883
(909)833-8996 CBL# 6876
USE OF PERMIT
SINGLE FAMILY DWELLING
WALLS, POOL, SPA OR DRIVEWAY APPROACH
CUSTOM CONSTRUCTION 2,208,00 SF
PORCH/PATIO 221.00 SF
GARACIE/CARPORT 518.00 SF
EgrIMTED COST OF CONSTRUCTION
185,095.30
PERMIT FEE SUA04ARY
CONSTRUCTION FEE 101-000-418 -000 $940.50
PLAN CHECK FEE 101-000-439-318 $756.99
MECHANICAL FEE 101-000.421-000 $75,00
ELECTRICAL FEE 101-000-420-000 $121.14
PLUMBING) FEE 101.000.419-000 $142.00
STRONO MOTION'FEE - RESID 101-000-241-000 $18.51
GRADING FEE 101-000-423-000 $15.00
DEVELOPER IMPACT FEE $2,407.00
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$4,476.14
LESS PRE -PAID FEES
$0.00
TOTAL PERMIT FEES DUE NOW
$4,476.14
RECEIPT
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