10-0426 (PLBG)P.O. BOX 1504
WORKER'S COMPENSATION DECLARATION
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA
92253
Application Number:040:0U_0_0_42-6
Property Address:
50965 CALliE PALOMA
APN:
770-104-004-80 -000000-
Application description:
PLUMBING
Property Zoning:
LOWS DENSITY RESIDENTIAL
Application valuation:
800
T4ht 4 4, QW lk-&
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Owner: U
COVER WILLI L/
50965 CALLE AL
LA QUINTA, 922
Contractor:
Applicant: Architect or Engineer: AZUL POOLS
48934 BUENA VISTA DRIVE
MORONGO VALLEY', CA 92256
(760) 3.63-6340
Lic. No.: 841585
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
177 `7
010 1Aj
5/17/10
-----------------------------------
LICENSED CONTRACTOR'S DECLARATION
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of. Chaptei 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 self -insure, for workers' compensation, as provided
License Class: C53 License No.: 841585 -
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
•' '• a r
_
ractor:.• -I
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
- OWN B DER DECLARATION -
insurance carrier and policy number are: -
. I hereby.affirm under penalty of perjury that.) am axe t from the Contractor's State License Law for the
Carrier DELOS INS CO Policy Number 02DKRM22004701
following reason (Sec. 7031.5,':Business and Professions Code: Any city or. county. that- requires a permit to
_ I certify that, in the performance of the work for which this permit is issued, I shall not employ any
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the
person in any manner so as to become subject to the workers' compensation laws of California,
permit to file a signed statement that he or she is licensed pursuant to the . provisions .of the Contractor's State
and agree that, if I should become subject.to the workers' compensation provisions bf Section.
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
3700 of the Labor C e, I Aall fort ith comply with those provisions.
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).:
te: plicant:
(_ 1 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
WARNING: FAILURE TO SECURE WORKERS' CO E TION COVERAGE IS UNLAWFUL, AND SHALL
Contractors' State License Law does not apply to an owner of property who builds or improves thereon,
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND -CIVIL FINES UP TO ONE HUNDRED THOUSAND
and.who does the',work himself or Herself through his or her own employees, provided that the
DOLLARS 1$100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES, AS PROVIDED FOR IN
improvements are not intended or.offered.for sale. If, however, the building or improvement is sold within
SECTION 3706 OF THE LABOR CODE, -,INTEREST, AND ATTORNEY'S FEES.
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.). .._-
APPLICANT ACKNOWLEDGEMENT
(_ 1 I, as owner of the property, am exclusively 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 Contractors' State License Law does not apply to an owner of
conditions and 'restrictions set forth on this application: i
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 to the Contractors' State License Law.). -
whose benefit,work,is performed under or pursuant to any permit issued as a•resuIt of this application,
(_ 1 I am exempt under Sec. , B.&P.C. for this reason
the owner; �and.the applicant, each agrees to, and shall defend,.indemnify and hold harmless the City
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
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 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 county ordinances and state laws relating to buildin ons coon, nd hereby authorize representatives
of this county to enter upon t above-mentioned property or i s e tion poses.
Date: ��27Si ature (Applicant or Agent):
t_
Application Number . . . . . 10-00000426
Permit . . . PLUMBING
Additional desc .
Permit Fee 18:00 Plan Check Fee
4.50
Issue Date Valuation
0
'Expiration Date 11/13/10
Qty Unit Charge Per
Extension
'
BASE FEE
15.00
1.00 3.0000 EA PLB GAS PIPE 1-4.OUTLETS
3.00
Special ,Notes and. Comments-.
R80. L . 2" GAS LINE TO SUPPLY POOL
HEATER:•• 2A07.� CODES
------------------="-------------------------------="----------
Other Fees` .. . . . . . . BLDG.'STDS ADMIN (SB1473);..
----------
` "1.00
Fee summary..._ Charged Paid Credited
Due
-_------ --- ------------- --- -
:.Permit Fee; Total 18:00•., :-:00 00
18' 00'
r _
P,lan' Check Total 4.50.. 00,; 00
°Other Fee Total 1.00. Oe- 00,
1.00
Grand Total .. 23.50. •00' -.00
23.50
LQPERMIT
Bin #
Qtyof La Quinta
Bu11d1ng.. 8T Safety
P.O. Box 1504, 78-495 Calle. Tampico
La Quint;, CA` 92253- (760) 777-7012
Burld►ng Permrt:Application,and. TrackrnglSheet
Permit #'Dh*166
h
Project Address: 50 01 Ej
Owner's Name: 5p k h V
A: P. Number:
Address: d. C, (I �A l
Legal Description:
Contractor: e,
City, ST, Zip: L Q - Z Z
Telephone.:,
Address:uDescription:• ' ��•
Project o
City, ST, Zip: I Co.
Telephone:
State Lie. # : C3 City Lie. #; '
Arch., Engr., Designer
Address:
City., ST, Zip:
Telephone:
State Lie. #:Project
Name of Contact Person:
Consttruction Type: Occupancy:
type (circle one): -New Add'n Alter Repair Demo
Sq. Ft:
# Stones:
# Units:
Telephone # of Contact Person: C 6 D� L{ g " D Z t{ S
Estin►ated. value of. Project
APPLICANT:'.DO NOT WRITE BELO'THISIINE
N
Submittal.
Req'd
Reed
TRACKING .
PERMrF FEES
Plan Sets
Plan Cheek submitted
Item
Amount
Structural Cala.
Reviewed,.ready for. corrections
Plin Check Deposit
Truss Calls.
Caued' Contact Person
Plan Check Balance
Tide 24 Cales.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechaotcalr�
Grading plan
2*' Review, ready for corrections/issue
ElecMeal .•
Subcontactor list
Called Contact Person
-
'Plumbing .
Grant Deed
Plans picked up
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
''d Review, readyfor correctionstissue
�Devdoper Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
•Total Permit Fees