12-1140 (BLCK)11
P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Tit!t 4 4 Q"
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
VOICE (760) 777-
• FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 9/26/12
Application Number: 12=0000114'0� Owner:
Property Address: `78405 COYOTE CANYON CT MICHAEL BALMUTH
APN: 770-240-005- - - 78405 COYOTE CANYON CT
Application description: WALL/FENCE LA QUINTA, CA 922
Property Zoning: LOW DENSITY RESIDENTIAL
Application valuation: 1125
Contractor:.
Applicant: Architect or Engineer: PREMIER BUILDRS
P.O. BOX 1329/ 0
INDIO, CA 92202 ClTyO�
��� (760) 296-1726 �rMA� gUly7
Lic. No.: 958992
LICENSE ON RACTO CLARATION WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury that I am cense er ovis' ns of Chapter 9 (commencing with I hereby affirm under penalty of perjury one of the following declarations:
Section 7000) of Division 3 of the Business an Profe onal ode, nd 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
Lice se CI ss: B ens o.: 958992 for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
a 1 IZ _ issued.
Date: VV ontractor: 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
OWN BUILDER DECLARATION insurance carrier and policy number are:
I hereby affirm under penalty of perjury that 1 am exempt from the Contractor's State License Law for the Carrier EXEMPT Policy Number EXEMPT
following reason,ISec. 7031.5, Business and Professions Code: Any city or county that requires a permit to certify that, in the performance of the wort r w ich this permit is' , I shall not employ any
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the j person in any manner so as to become bjec o the workers' mp sation 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 s ject t t o kers' pe tion provisions of Section
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 370 of the Labor Code, I shall f hwi co ply th t se p isions.
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).:
at
licant:
(� 1 I, as owner of the property, or my employees with wages as their sole rnmpensatinn, 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 WORK S' COMPENSATION C VERAGE 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 ENALTIES 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 ($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 nr 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.
property who builds or improves thereon, and who contracts for the projects with a contractor(sl 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 I am exempt under Sec. , BAP.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: P.
LQPERMIT
of La Quetta, 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 th o e info i n i rrect. I agree to comply with all
city and county ordinances and state laws relating to b ding on uction d here y authorize representatives
of this f�oun to nter u on the above- antioned pr art r i pectio rpose .
te: ( gnature (Applicant or Agan r
Application Number . . . . . 12-00001140
Permit . . . WALL/FENCE PERMIT
Additional desc . .
Permit Fee . . . . 29.00
Plan Check
Fee
.00
Issue Date . . . .
Valuation
. . .
. 1125
Expiration Date . . 3/25/13
Qty Unit Charge Per
Extension
BASE
FEE
15.00
7.00 2.0000 HND BLDG
501-2,000
14.00
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Special Notes and Comments
3 WALLS TOTALING 45 L.F. 6' HIGH,
CITY
STANDARD. 2010 CODES.
----------------------------------------------------------------------------
Other Fees . . . . . . . . . BLDG STDS ADMIN (SB1473)
1.00
Fee summary Charged
Paid Credited
----------
Due
-------------------------------------
Permit Fee Total 29.00
----------
.00
.00
29.00
Plan Check Total .00
.00
.00
.00
Other Fee Total 1.00
.00.
.00
1.00
Grand Total 30.00
.00
.00
30.00
LQPERMIT
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