09-1020 (SPIN)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253 BUILDING &"SAFETY•DEPARTMENT
BUILDING PERMIT
Application Number. X09 '007003020. Owner:
Property Address: 8-9865=PASE6DE ROSARI0 R.T. HUGHES
APN: 766-110-016155 -33597 - 78900 AVENUE 47, STE
Application description: SPECIAL INSPECTION LA QUINTA, CA 92253
Property Zoning: LOW DENSITY RESIDENTIAL.
Application valuation: 100
Contractor:
Applicant: Architect or Engineer: DANTOR MARTINEZ CON#
81057 AVENIDA ROMEAO
INDIO,.CA 92201
(760) 70 929. (/ LiC. No.:' 926128
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760).777-7153
200
P
Date: 9/22/09
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LICENSED. CONTRACTOR'S DECLARATION
- WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty.of perjury that I am licensed; under provisions of Chapter 9 (commencing with
1 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.
_ 1 have and wilFinaimain a certificate of consent to self -insure for workers' compensation, as provided
License Class: B. 'cense No.: 926128,
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
p '.. ,.
Z
ssued:
to 1" '� ontractor:
1 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
' •' OWNER -BUIL DE RATION
. -. insurance carrier and policy number are: -
i..hereby affirm under penalty of perjury that Iam-exempt from the;. - ontractor's State. License Law for the
Carrier 7 MPT - - ... Policy Number c `EXEMPT
following: reason.(Sec. 7031.5; Business. and Professions Code. Any 6tyor.county that-requireIs a -permit to
&I certify that, in the performance of the workfor which this permit is issued, I shall not employ any
'construct, alter, improve, demolish, otrepair.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 orshe is licensed pursuant to the provisions.of.the Contractor's State
and agree that, if I should become, subject to the workers' compensation provisions of Section
License Law (Chapter 9�(comme6cing'v ihh Section 7000) of.Division 3'of the Business and Professions Codel or
3700 of the Labor INe, I shall f rthwiih mply with ose 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).:
_
ate:'R plicant:
1 1 I, as owner,of the property, er my'employees with wages as their sole compensation, will do the work, and
- the structure isnot intended or offered for sale (Sec. 7044, Business and Professions Code: The .
wARNINGr FAIL RE TO SECURE WOR ERS' COMPENSATIO, COV RAGE 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.. E UP TO ONE HUNDRED THOUSAND
and who does the work himself•or, herself through his or her own employees, provided that the
DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENS TION, 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 ATTOFIN EY" S -FEES.
one year of completion, the owner -builder will have the bur6n of proving that. he or she did not build or
-
improve for the purpose of sale.). -
APPLICANT ACKNOWLEDGEMENT
I _) 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.
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 result of this application,
1 _ 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
-of La Quints, its officers, agents and employees for any act or omission related to the work being
performed under or following issuance of this permit.
-
Date: Owner:
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
CONSTRUCTION LENDING AGENCY
permit to cancellation.
I hereby, affirm under penalty of perjury that there is•a construction lending agency for the performance of the
I certify that I have read this application and state that the above information'is correct. I agree to comply with all
work for which this permit is issued (Sec. 3097, Civ. C.).
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
of thi - county to ant upon the above-mentioned pr rty for inspe ion pure ses. '
Lender's Name:
�-
ate: Signature (Applicant or Agent): -
Lender's Address:
LQPERMIT
V
LQPERMIT
Application Number . . . . . 09-00001020
Permit SPECIAL INSPECTION
Additional desc . .
Permit Fee . . . . 100.00 Plan Check
Fee
.00
Issue Date . . . . Valuation
100
Expiration Date 3/21/10
Qty Unit Charge Per
Extension
BASE FEE
100.00
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Special Notes and Comments
SPECIAL INSPECTION TO COMPLETE.
CONSTRUCTION OF SFD. REFER TO PREVIOUS
PERMIT # 07-1275.
Fee summary Charged Paid Credited
Due
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Permit Fee Total 100.00 .00
----------
.00
100.00
Plan Check Total .00 .00
.00
.00
Grand Total 100.00 .00
.00
100.00