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05-1853 (BLCK)P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: Propetfy Address: APN: Application description: Property Zoning: Application valuation: Applicant: BUILDING & SAFETY DEPARTMENT BUILDING PERMIT 05-00001853 81214=SANTA ROSA CT 764-2701999-21 -300234- n WALL/FENCE I hereby affirm under penalty of perjury one of the following. declarations: MEDIUM HIGH DENSITY .RES 4020 JUN O 3.2005 4 I have:and'will maintain a certificate of consent toself-insure for workers' compensation, as provided CITY OF LA QUINTA Architect or Engin FINANCE DEPT Owner: SHEA.LA QUINTA C/O JEFF MCQUEEN- 8800 N GAINEY CENTER 350 SCOTTSDALE, AZ 85258 J Contractor: SHEA HOMES,. INC. 81260 AVENUE 62 LA QUINTA, CA 92253 .1(7601777-6005 Lic. No.: 672285 VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 5/24/05 LICENSED CONTRACTOR'S -DECLARATION ------------------------------------- WORKER'S COMPENSATION �DECLARATION hereby affirm under penalty of perjury that-I'am licensed under pr`ovisions'of-Cllapter-9 (commencing"with s I hereby affirm under penalty of perjury one of the following. declarations: . Section Z000).of'Division 3 of the:8usiness and ProfessionalSCode; and my License•is in full force and effect. I have:and'will maintain a certificate of consent toself-insure for workers' compensation, as provided License C - B •' ' License'Nd.: 6,72285 _ for by Section 3700 of the -Labor I Codefor the performance of'the,work for which this permit is _ 01'�-ntr&��/S _ ssued�tei�ctor: I have and will maintain workers -compensation insurance, as required by Section 3700 of theLab or , Code, for the performance of the work -for which,_thispermit is issued. My workers' compensation • .;� OWNER -BUILDER DECLARATION •insurance carrier and policy number are:. . I hereby affirm under penalty of perjury4that I am exempt _from the-:Contractor's*State License Law for the Crrier.•NTL UNION -INS Policy Number..•,6436568 following reason'lSec. 7031.5, Business and Professions Code:.;viy city or�county thatrequires a permit to _ I certify that, in the performance of the work for which this permit is issued, I shalllnot employ any construct .alter; improve demolish; orrepair any structure.; prior to its issuance, also requires the applicant,for the person in anymanner:so as. to become subject to the workers' compensation laws of California, permit to file a'signedstatement that he:or.she is lid'ensedipursuant to the ;provisioris of the Contractor's State - and;P ree that, if I should become subject to She workers' compensation provisions of Section_ License Laws (Chapter 9 (commencing wi6:Section;7000) of Division3 of the Business and 'Peofessions Code) or 3700 of the Labor Code shall fortith complywith those provisions. -that'he or she is exempt therefromand the basii,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 IS500):: (_ 1 I; as owner of. the property„or my,employees with wages as their_Sale compensation,' will d - the work, and - - . the structure ii not intended or•offered for sale (Sec:.7044, Business and Professions;Code: The WARNIN :'FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS -UNLAWFUL, AND SHALL Contractors' State License Law does not apply to an owner ofproperty Who builds or'improves thereon, SUBJECT AN EMPLOYER TO CRIMINAL PENALTIESAND CIVIL FINES UP:TO ONE,HUNDRED. tFiduSAND and who does the Work himself or.herself.through his.oi her own employees, provided that the DOLLARS $100,000): IN ADDITIONITO.THE-COST OF COMPENSATION,.DAMAGES AS PROVIDED'FOR IN improvements are not intended or: offered forsalet,klf however; the building.or improvement is sold within SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY' SFEES: one year of completion; the owner= builder will hale the burden of proving that he or she did not build or - t •.. improve for the purpose of sale.). - - APPLICANT ACKNOWLEDGEMENT m (_ 1 I, as owner of the property, aexclusively contracting with licensed contractors to construct the project (Sec. IMPORTANT Application is hereby,made to the Director'of Building and'Safety for a permit subject to the 7044, Business and .Professions Code: `.The State License Law does not apply to an owner of conditions and restrictions set forth an.this application. - Contractors' ,. property who builds or'improves thereon, "and who contracts for the projects with a contractor(s) licensed 1. Each person upon whose behalfthis, application. is made, each person at whose request and for pursuant to the Contractors' State License Law.). ' . whose benefit work is performed under or pursuant to any permit issued,as a result of this application, (_ I I am exempt under Sec. , B.&P.C. for this reason the owner, and the. applicant, each agrees to, andshall defend, indemnify and hold harmless the City of La Quina, its officers, agents and•employees for any act or omission related to the work being performed under or following issuance of thispermit. Date: Owner: 2. Any -permit issued as a result of this application becomes null and void if work is not commenced 4 •— within .180 days from date of issuance of such permit, or cessation of work for. 180 days will subject ' CONSTRUCTION LENDING AGENCY permit to cancellation. - 1 hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the I certify that I have read this application and state that the above information is correct. I agree to comply with all work for which this permit is issued (Sec. 3097, Civ. C.). city and county ordinances and state laws relating to building construction, and authorize representatives Lender's Name: of this county o enter "on the above-mentioned property for i spection p ses. - . _ ate: Signature (Applicant or Agent): ' Lender's Address: LQPERMIT Application Number . . . . . 05-00001853 Permit. . . . WALL/FENCE-.PERMIT Additional desc . ' Permit Fee . . . . 72.00 Plan Check Fee .00 Issue.Date Valuation . . . . 4020 Expiration Date 11/20/05 Qty Unit Charge Per Extension :BASE FEE 45.00 3 .'00 9.0000•: THOU BLDG ;2, 001=25., 0.0.0. 27.00 - ---- �.• :,, .;., .. -Notes- and Comments ' Speciesl -- ---------------- - - - - -, -T-. - - - - - -- ._ ._ 100 L._ 6' :GARDEN. WALL, ::95 L _F:. 3' RETAINING.WALL.,`BOTH ORCO'SYS TEM Fee summary Charged Paid.' Credited Due 77 - - - - - -.- Permit Fee Total 72.00. --- - ----- ---- -- - - --- 00 .00 --- - - - - -- 72.00 . Plan Check Total 00 ...00 .00 .0.0 Grand Total 7:2 00-- • 00 00 -7.2'.00;,:;