08-0569 (PLBG)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Applicant: Architect or Engineer:
I -Xjkh
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LICENSED CONTRACTOR'S DECLARATION
4
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
1 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 License is in full force and effect.
License Class: C36 License No.: 519999
Date: Contractor: '
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 ($5001.:
(_) 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 _ 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, d who contracts for the projects with a contractor(s) licensed
pursuant to the Contractors' State Licens .).
(_ 1 I am exempt under Sec. , B.&P.0 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: 4/07/08
Owner: '
MORRIS RICK E
51525 AVENIDA JUAREZ iJ
LA QUINTA, CA 92253
(
Contractor: 4PR 0(9
JD MECHANICAL INC C/%y.OF
S ENTREPRENEUR
PALMDESERT, CA 92211
�NA�CF EP/��iq l
(760)360-0711 /
Lic. No.: 519999
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WORKFR'S 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.
_ I 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 GOLDEN EAGLE IN Policy Number WEN0011338-02
_ I certify that, in the performance of the w rk for which this permit is issued, I shall not employ any
person in any manner so as to becom subject to the workers' compensation laws of California,
and agree that, if I should become s ject to the workers' compensation provisions of Section
370�the Labor Code, I shall for ith rnmply with thosc provisions.
'Date: l �� 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 to cancellation.
I certify that I have read this application and state th the above information is correct. I agree to comply with all
city and county ordinances and state laws relating uilding construction, and hereby authorize representatives
of this cpun7ttyyf to ent7e}rIuupon the above-mentioned perty for inspection purp�5es.
Date _8 to ignature (Applicant or Ag
-- - LQPERAIIT_.-
Application Number . . . . . 08-00000569
Permit . . . . . PLUMBING SEWER
Additional desc .
Permit Fee, .. 30.00.
Plan Check
Fee
.00
Issue Date
Valuation
. . .
. 1800
Expiration Date 10/04/08
Qty Unit Charge Per
Extension
BASE FEE
15.00
1.00 15.0000 EA PLB BUILDING SEWER
15.00
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Special Notes and Comments
SEPTIC ABADONMENT/ SEWER HOOK-UP
Fee summary Charged Paid
-------------------------------------
Credited
----------
----------
Due
Permit Fee Total 30.00
.00
.00
30.00
Plan Check Total .00
._.00
.00
.00
Grand Total 30.00
.00
.00
30.00
*W>
COACHELLA VALLEY WATER DISTRICT CASH RECEIPT DETAIL 1
+2285 _ Date: /09
Received From:
_.,Address: Tract
v �. • �Vt-4
Lot(s)3 "Account No. G.A. Code
i 4
Service Address $
❑ Meters)
❑ Service(s)
❑ ,Backflow(s)
., :❑ ,House Lateral(s)
' ❑ Detector Check(s)
,,❑ .Meter Surcharge
Sanitation Capacity Charge —
�;' ❑ 'W.S.B.F.C.
❑ . S.I.W.S.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑Uncollected Account - Name
❑ Inspection Fee -Tract - .�
Fee -
C1 Plan Check Fees Water /Sewer- f
I ract
4 --�
Assmt
❑ Bond Payment -A.D. -
Bond
❑ .Customer Deposit
❑ Other I
;Remarks:
apy_to:
Cash 1` -53
- Money -
Order ,
OF
d
.00
Water Service'
Cashier
CVWD-438 (1/05)
Bin #.
1 .
Permit #
qol�
g�
FProject Address:'
A. P. Number:
Contractor:
Address: G
City, ST, Zip:
Telephone:' U0 LO T517
17
State Lic. #
Arch., Engr., Designer: .
Address:
City, ST, Zip:
TI h •
City of La Quinta
Building U Safety Division
P.O. Box 1504, 78-495 Calle Tampico '
La Quints, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
.UA11're Z— Owner's Name: .L�r., 1
Address:
City, ST, Zip:
i_(..r -Telephone:
Project Description:
Lic. #:
e ep one.
Construction Type:
0' , an
P cy:
State Lie. #:
Project type (circle one):
New Add'n 'Alter Repair Demo
Name of Contact Person:
nn 1A e,
�L/'�./_:
'
Sq. Ft.:
t`'l
#
Stories:.
#Units:... .
Telephone # of Contact -Person: � �.
Estimated Value .ofProject: Fee
APPLICANT: DO NOT WRITE BELOW THIS LINE
..
.
# Submittal
Req'd - Rec'd
TRACMG .
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed; ready for corrections
Plan Check Deposit
Truss Cates.
Called Contact Person
Plan Check Balance
Energy Cates.
Plans picked up
Construction '
Flood plain plan,
Plans resubmitted
Mechanical
Grading. plan
2i° Review, ready for correctionslssue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant'Deed
Plan§.picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:
''' Review, ready for correctionsrssue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees