05-1627 (RER)jA
P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
Property Address:
APN: '
'Application description:
Property Zoning:
Application valuation, 4
Applicant:
05'-}0000162
57576 SANTA ROSA TR D
762-240-013-20 -34087
REMODEL - RESIDENTIAL ff
DENS IT.
Architect or
I
BUILDING &.SAFETY DEPARTMENT
BUILDING PERMIT
Owner
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777=7153
---------------------------------
/�\ SANTA ROSA DEV
40847 SANDPIPER CT
PALM. DESERT, CA 92260
JUN 0 2 2u :,..
CITY OF LA QUINTq Contractor:
r: FINANCE DEPT.____.
GREYRAWK INC
Date: 6/01/05
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:
5
LQPERMIT
• perf6rrmed 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 infor tion is correct. I agree to comply with all
city and county ordinances and state laws relating to building c ruction, nd hereby authorize representatives
o/f t/ttis county to er upon the above-mentioned pr/op/e�ty inspection p poses.
9 co. Signature (Applicant or Agentf: '
1603 TRASKE ROAD
ENCINITAS,., CA -92024
Lic. No.: EXEMPT ,
----------------•-----------------------
- LICENSED CONTRACTOR'S DECLARATION
------------------------------------------------
WORKER'S COMPENSATION DECLARATION
. „1. hereby affirm under penalty of. perjury that I am licensed under provisions of Chapter,9 (commencing with
I hereby affirm under penalty, of perjury one of the following declarations: • - "
Section'•7000) of Division 3 of the Business and Professionals Code, and my License is in full.force'and effect.
_
I have and will maintain a certificate of consent to -insure for workers' compensation, as provided
License'Class:.798228 - - -License No.: -EXEMPT .;-+-
_ _self
for by Seciion•3700 of,the Labor Code, for the performance of'the work for which this peimit is
c /,. ,,.._ y - .'i•
'
.. Date:cMt�a� 3
,/ issued.'.,"`. •...; •� -,.. '
/V I have insurance;'as 3700 Labor -
,Contracto t
--Code,
. and'will'maintain;workers;compensation required by`Section of'the
for the performance of the work'for which this'permit is issued. M_ y workers' compensation-
OWNER -BUILDER -.DECLARATION'.•
insurancecarrier and policynumberare: •�• - as .�
' 1 hereby. affirm under penalty of perjury that Iam exempt from•the Contractor's State License Law for the •
Carrier .1031 ' r PohcyNumber. EXEMPT `
following.ieason (Sec. 7031.5, Business and Professions Code: Any city or county that requires a permirto
•
I certify that; in the performance of the work for which this permit is issued, I shall not,employ any
'of
construct,;alter,;improve; demolish, or, repair any structure prior to its issuance; also requires the applicanrforthe
�.
_
person in.any manner so as to become subject to the workers'; compensation laws California;
permit to file a signed statement that he or she is licensed pursuant t6the:provisions�of-the Contractor's State
and'agree that, if rshould oecorim' to the woikers' compensation, provisions oUSection
License Law (Chapter 9 (commencing with,Section 7000) of Division 3'of,the Business and Professions. Code)' or
/ 3700 of the Labor Code, I forthwith mply with those provisions. '
. that he`orshe is exempt therefrom and the basis for the alleged exemption. Any violation of Section,7031.5 by
any applicant fora permit subjects the applicant to a�civil, penalty of not more than five.hundred dollars (S500).: i .
Date:. Applicant.
I- I. l,.as owner of the property, or my employees with wages a's their soleiomperisation, will do the work,.and
- the structuie is not intended or offered for sale(S,ec=.7044 Business and:P,rofessions Code:' The
WARNING: ,FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS. UNLAWFUL,. AND SHALL -
Contractors' State License Law does not apply to:an'owner of_pioperty who builds or improves thereon,
.SUBJECT'ANEMPLOYER TO -CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND -
+. and who•does the work himself-orherself through his or her oovn employees,provided-thaYthe'
'DOLLARS`.(s100,000)., IN ADDITION TO THE COST`OF COMPENSATION, DAMAGES AS PROVIDED FOR IN.
" improvements,arenot intendad or offered for�sale.%If,-however;,theiTtiuilding or improvement is�sold within •
SECTION -3706 OF THE LABOR.CODE, INTEREST, AND AT_ TORNEY_S FEES. '
.one year of completion, the downer -builder will have the burden of proving that he ovshe did,not build or
'
s - •i
improve for the purpose of, sale.). - - '
•! APPLICANT ACKNOWLEDGEMENT
_
(_) I, as owner of the. property,'am exclusively contracting witA licensed contractors`to construct'the project (Sec.
IMPORTANTApplicationishereby made to the Director'of Building and Safety for a permit subject to the
' 7044, Business and'Professions,Code: The Contractors' State License Law'does not apply to an owner of
conditions and restrictions set forth on this application.
. property who builds�or improves thereon, and who contracts for the projects with a contractor(s) licensed
1.. Each person upon.whose behalf this application.is made, each person at whose request and for
pursuant-6the Contractors' State License Law.). °
whose benefit work is performed under or pursuant to any permit issued as a result of this application,
,hold
( '• 1 I am exempt under Sec. , B.&P:6.4or this reason
-the owner,'and,the' applicant, each agrees to, and shall defend, indemnify and harmless the City
- - • - -
' of La 0uinta'its officers- a ants and em toY •ees for an act or omission related to the work bein
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:
5
LQPERMIT
• perf6rrmed 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 infor tion is correct. I agree to comply with all
city and county ordinances and state laws relating to building c ruction, nd hereby authorize representatives
o/f t/ttis county to er upon the above-mentioned pr/op/e�ty inspection p poses.
9 co. Signature (Applicant or Agentf: '
r;0
Application Number . . . . . 05=000016.27
Permit . . . BUILDING PERMIT
Additional desc .
Permit Fee . . 37.00 Plan Check
Fee
24.05
Issue Date . . . . Valuation
. . .
. 1596
Expiration Date 11/28/05
Qty Unit Charge Per
Extension
BASE ,FEE
15.00
11.00 2.0000 HND BLDG 'S 0.1 - 2, 0 0 0
22.00
------ =-- -------------7 -----------------------------
Special'Notes and'Comments"
---------------
---
RESIDENTIAL -`COVERED ENTRY PORTICO
ADDITION 120,SQ..FT: TO RESIDENCE LOT 20
UNDER CONSTRUCTION PERM -IT TA04-7376':. TYPE
V -N CONSTRUCTION, 2&0-1 CODES.
Other `Fees HOURLY' PLAN CHECK
70'.00
STRONG MOTION .(SMI).
- RES
.50
Fee summary,` Charged Paid Credited
Due-.
Permit Fee Total 37.00 .0;0,
.00
37.00°
P1;ari Check Total. 24.05, 00
00
2,4..05'
Other Fee T6ta°1 70..50 : 00
: 00= .:.
70..50
Grand. Total 13.1 .55� ` .00 ..
00
131. SS•:.' :
LQPEn11T