04-6840 (RPL)fY
Tihf 4 4 a"
P.O. Box 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING PERMIT
BUILDING & SAFETY DEPARTMENT
_ (760).777-7012
FAX (760) 777-7011
INSPECTION REQUESTS (760) 777-7153
Application Number . . . . . 04-00,00684-0,__Date 10/19/.04
Property Address . . . . . . 53780 DEL GATO DR
APN: 770-370-010- - -
Application description . . . POOL - RESIDENTIAL
Property Zoning . . . . . . LOW DENSITY RESIDENTIAL
Application valuation . . . . 9500
Owner Contractor
CLEMENTS ROBERT E AINSWORTH POOL CONSTR, ROBERT
PALM DESERT CA 92211
(760) 568-4993
WCC: AU INS SRVC
yII��N
_ WC: 00500018173 01/01/05
CSLB: 598681 07/31/06
CCC: C53
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Permit . . . . . . BLDG POOL PERMIT
Additional desc
Permit Fee . . . . 117.00 Plan Check Fee 76.05
Issue Date . . . Valuation . . . . 9500
Qty Unit Charge Per Extension
BASE FEE 45.00
8.00 9.0000 THOU BLDG 2,001-25,000 72.00
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Permit . . . . . . ELEC POOL PERMIT -RES
Additional desc
Permit Fee . . . . 45.00 Plan Check Fee 11.25
Issue Date . . . . Valuation . . . . 0
Qty Unit Charge Per Extension
BASE FEE 15.60
1.00 30.0000 EA ELEC PRIVATE SWIMMING POOL 30.00
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Permit . . . . . . PLUMBING
Additional desc
Permit Fee 27.00 Plan Check Fee 6.75
Issue Date Valuation . . . . 0
Qty Unit Charge Per Extension.
BASE FEE 15.00
1.00 6.0000 EA PLB FIXTURE 6.00
1.00 3.0000 EA PLB.WATER INST/ALT/REP 3.00
1.00 3.0000 EA PLB GAS PIPE 1-4 OUTLETS 3.00
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Special Notes and Comments
COURTYARD FOUNTAIN
eN
P.O. BOX 1504 • VOICE (760) 777-7012
78-495 CALLS TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number: iD O40 Date: /D .X .Vf -
Applicant:
Applicant's Mailing Address:
Architect or Engineer:
Architect or Engineer's Address:
Lic. No.:
BUILDING PERMIT DECLARATIONS
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 Division 3 of the Business and Professionals
Code, and my Li n e is in full force and effect.
,,, -'License Class
License No..5!C044
I
/Date 10 1 '---Cont.ctor I ->,,4tifl144 �JLS
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors' 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 Contractors' 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).):
U 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 or 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.).
U I, as owner of the property, am exclusively contracting with I icensed. 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.).
U I am exempt under Sec. , BA P.C. for this reason
Date Owner
WORKERS' 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.
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
i ue M wpr�e�s corypensation i ce carrie{�
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 Califo and agr a that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall
forthwith comply with those p ovi 'ons.
nntp f 0h (/d 4
WARNING: FAILURE TO SECURE WORKEROMP NSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED THOU! D DOL RS ($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.
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 perrnit is issued (Sec. 3097, Civ. C.).
Lenders Name
Lender's Address
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 to Cancellation.
I certify that I have read this application and state that the info ation is correct. I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives of this ount to er upon the ove-mentioned property for inspection purposes.
G ignature (Applicant or Agent).
Application Number . . . . . 04-00006840
Page 2
Date 10/19/04
Fee summary Charged Paid Credited I Due
Permit Fee Total 189.00 .00 .00 189.00
Plan Check Total 94.05 .00 .00 94.05
Grand Total 283.05 .00 .00 283.05
Serft-By: AINSWORTH POOLS;
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Sent.By: AINSWORTH POOLS; 7602000040;
Oct -19-04 3:53PM;
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