05-2450 (BLCK)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
r� Application Number:
Property Address:
APN:
Application description:
Property Zoning:
Application valuation:
Applicant:
"0S-00002450
78680 CALLE TAMPICO
770-106-008-120 -000000-
WALL/FENCE
LOW DENSITY RESIDENTIAL
1516
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Architect or Engineer: 11D
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 License is in full force and effect.
License Class: - - - - - - - - - - License No.: C 2 9
Date: { Contractor:
IT7-
OWNER-BUI D LARATION
I hereby affirm under penalty of perjury that I am exempt fr th ontractor'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 ($500).:
(_) 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, 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, and who contracts for the projects with a contractor(s) licensed
pursuant to the Contractors' State License Law.).
1 _ 1 I am exempt under Sec. , B.&P.C. for 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
Owner:
OTT MANI & TRACEY
78680 CALLE TAMPICO
LA QUINTA, CA'92253
(760)564-9079
Contractor:
BLOCKWORKS INC DBA AA MASONRY
77530 DELAWARE PL
PALM.DESERT, CA 92211
JICC: ISTATE FUND
Lic. No.: C29
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 6/17/05
WORKER'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.
have and will maintain workers' compensation insurance, as requiredby 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 0460013301 06/08/0SolicyNumber 804168
_ 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 California,
and agree that, if I should become subject to the workers' compensation provisions of Section
700 of the Labor Code, I shall f rt ith comp) ith those provisions.
/Date: ,Applicant:
WARNING FAILURE TO SECURE W KERS' COMPENSA NCO RAGE 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, INTERF_ST, 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 workis 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 ouinta, 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 building construction, and hereby authorize representatives
of this county to enter upon the above-mentioned property for inspe ' n urposes.
Date:, � t
7 % Signature_IApplicant or Agent):
Application Number . . . . . 05-00002450
• Permit WALL/FENCE PERMIT
Additional desc .
Permit Fee 37.00
Plan Check
Fee
.00
Issue Date.
Valuation
1516
+ Expiration Date 12/14/05
Qty Unit Charge Per.
Extension
BASE FEE
.15.00
11.00 2.0000 HND BLDG 501-2,000
22.00
- ---------------------------------------------
Special Notes and Comments
70 LF 5' BLOCK WALL WITH 4 -COLUMNS.
ORCO DETAIL
Fee summary Charged Paid
Credited
Due
---------
Permit Fee Total 37'.00,
----------
.00
-
.00
37.00
Plan Check Total •.00
,00
.00
.00
Grand Total 37.00
.00
.00
37.00
LQPERMIT
.
CITY OF LA CONTA
A RE -INSPECTION `FEE OF $30
BUILDING & SAFETY DEPT.
WILL BE CHARGED IF THE APPROVED
APPROVED
PLANS AND JOB CARD. ARE NOT ON
FOR CONSTRUCTION ;
.
THE SITE FOR A SCHEDULED
kt
DATE` ��BY
INSPECTION.
NO EXCEPTIONS!
LIS
it
T
70 : t , x
s` G,,
C)Tt
"TaOf
A
• .`1
bCj Ate," 1' ju cz
L��n��