05-2020 (BLCK)e
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P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA
Application Number:
Property Address:
APN:
Application description
Property Zoning: _
Application valuation:
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44Q"
::RILDING & SAFETY DEPARTMENT
BUILDING PERMIT
05000020.
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762-2 S
762-240-01L-2
WALL/FENCE
LOW DENSIT
0 p 12N5
110A
Applicant: Architect or Engineer:
1— I
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with
Section 7000) of Div' ion 3 of the Business and Professionals Code, and Lic n e is in full force and effect.
D�xe: Contraa/
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 ($500).:
(_) 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 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 (Sec. 3097, Civ. C.).
Lender's Name:
Lender's Address:
LQPERMIT
VOICE (760) 777-7012.
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 5/26/05
Owner:
---------------------------------
SANTA ROSA DEV x
40847 SANDPIPER CT
PALM DESERT, CA 92260
Contractor:
CASA VERDE LANDSCAPE MAINT COR
WCC: GRANITE
WC: 9549987 09/05/05
Lic. No.: ---------------
------------------
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
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.
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 624647 0 8 /3 1 / 06olicy Number C-27
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
� 7700 of the Labor Code, I shall forthwith comply with those provisions.
DW: ! Applicant:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES 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,6 cancellation.
I certify that I ave read this application and state that the above information is c ct. I agree to comply with aj1
city and cou ty ordinances and state laws relating to buildi construction, hereb authorize representatives
of this c�tto terupon the above-mentioned grope inspe do urposes.Date:Signature (Applicant or Agentl:
LQPEnUT
Application Number 05-00002020
Permit . . . WALL/FENCE PERMIT
Additional desc .
'Permit`Fee 54.00 Plan Check Fee .00
Issue Date. . . . Valuation 2950
Expiration Date 11/22/05
Qty Unit Charge Per Extension.
BASE FEE 45.00
1.00 9.0000 THOU BLDG 2,001-25,000 9.00
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Special Notes and Comments
118 L.F. 6' BLOCK WALL, CITY STANDARD.
Fee -summary Charged Paid. Credited Due
Permit Fee Total 54..00 .00 .00 54.00
Plan Check Total .00 .00 .00 .00 ,
Grand Total 54.00 .00 .00 54.00
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