04-4793 (RPL)ar.
�. °
BUILDING & SAFETY DEPARTMENT
1504
(760).777-7012
- cF 8- LLE TAMPICO FAX (760) 777-7011
LA QU , CALIFORNIA 92253 INSPECTION REQUESTS' (760) 777-.7153
JUN 0 8 1004
BUILDING PERMIT
CITY OF LA.QUINTA
FINANCE DEPT.
Application Number . . . . 04-00004793 } Date 6/07/04
Property Address ... . . 810I0 SHINNECOCK HILLS
APN: 762-330-001-1 -29147
Application description POOL - RESIDENTIAL
Property Zoning . . . . . LOW DENSITY RESIDENTIAL
Application valuation 17000
Owner Contractor
SOUTHERN HILLS DEVELOPMENT RIPARIAN ENVIRONMENTS
55161 SOUTHERN HILLS P.O. BOX2391106
LA QUINTA CA 92253 ANZA CA 92539
(909) 763-0645
WCC: STATE FUND
WC: 1769754 04/12/05
CSLB: 839002 05/31/05
CCC: C8 -C27 -C29-053
Permit . . . . . . BLDG POOL PERMIT
Additional desc
Permit Fee. 180.00 Plan Check Fee 117.00
Issue Date Valuation .17000
Qty Unit Charge Per Extension
BASE FEE 45.00
15.00 9:0000 THOU BLDG 2,001-25,000 135.00
-------=------------7-------------------------------------------------------
Permit MECH POOL
Additional desc
Permit Fee . . . . '24.00 Plan Check Fee 6.00
Issue, Date . . . . Valuation . . 0
Qty Unit Charge Per Extension
BASE FEE 15.00
1.00 9.0000 EA MECH FURNACE <=100K 9.0}0
-----'------------------------------- ---------7-------------------------------
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 15.00
1.00 30.0000 EA ELEC PRIVATE SWIMMING POOL 30.00
P.O. Box 1504 _ T- 4 aod4f
78-495 CALLE TAMPICO " .
LA QUINTA, CALIFORNIA 92253 4
BUILDING & SAFETY DEPARTMENT
Application Number:
Applicant:
Applicant's Mailing Address:
VOICE (760) 77;-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date:
Architect or Engineer:
Hrcrinect or tnglneer's Add r ss:
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 Lice£se i 11 force and effect. n
License Class License No. 75
�p
Date Contrector �(/f t7 (r0 k 1'IM I
t v
I herebyaffirm under OWNER43UILDER DECLARATION
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 licensed contractors to construct the project (Sec. 7044, Business and Pro
State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects wiessions Code: The Contractors*'
th Professions
contractor(s) licensed pursuant to
the Contractors' State License Law.).
U 1 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.
I hae 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 ed. Y ��r� compensation insurance cartier p c r .
Cartier�Ue 1 Polity Number
_ I certify that, in the performance of the work for which this p y y person in any manner so as to become subject to the workers'
• permit is issue , I s all n� of em Io an
compensation laws of California, greein , if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall
forthwithcomply with those pr rsi ns.�
Date — �� % Applicant
WARNING: FAILURE TO SECURE WORKE S' C 104NSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED THOUSAND D'OLLARS ($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.
I herebyaffirm under CONSTRUCTION LENDING AGENCY
penally 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
IMPORTANT APPLICANT ACKNOWLEDGEMENT
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 pursuato an
issued as a result of this application, the owner, and the applicant, each agrees to, and shall, defend, indemnity and hold harmless the City of Le Quints, i spermrt
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 day! from date of issuance of such permit or
cessation of work for 180 days will subject permit to cancell 'on.
I certify that I have read this applicatiori and state that the above inf alio is tro I agree to comply with all city and county ordinances and state laws rotating to building
construction, and hereby authorize representatives of this county t en t , upon above-rrmentioned property for inspection purposes.
Date Signature (Applicant or Agent):
Page 2
Application Number . . . . . 04-00.0047.93
Date' 6/07/04
------------------------------------------------- ---------------------------
Permit . . . PLUMBING
Additional desc
Permit Fee . . . . 33.00 Plan Check Fee
8.25
Issue Date .`Valuation . .
. . 0
Qty'. Unit Charge Per.
Extension
BASE FEE
15.00
2.00 6.0000 EA' PLB FIXTURE
12.00
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
-------------------------------------------------------------.---------------
Special Notes and Comments •
POOL/SPA. ALARMS/BARRIERS SHALL BE IN
PLACE AT PRE -PLASTER INSPECTION.
EQUIPMENT ENCLOSURE NOT INCLUDED
Fee summary Charged Paid Credited
-----------------
Due
------- - -- ---------- ----------
Permit Fee Total 282.00 .00 .00
----------
282.00
Plan Check Total 142.50 .00 .00
142.50
Grand Total 424.50 .00 .00
424.50
J
BUILDING & SAFETY DEPARTMENT
P.O. Box 1504 (760).777-7012
78-495 CALLE TAMPICO FAX (760).777-7011
.LA QUINTA, CALIFORNIA 92253 INSPECTION REQUESTS (760) 777-.7153
BUILDING PERMIT
Application Number . . .
. .. 04-00004793 Date
6/07/04
Property Address
81010 SHINNECOCK HILLS
APN:762-330-001-1
-2914.7
Application description .
. POOL -RESIDENTIAL
Property Zoning
LOW DENSITY RESIDENTIAL .
.Application valuation
17000
Owner
Contractor
.SOUTHERN HILLS DEVELOPMENT
RIPARIAN ENVIRONMENTS
55161 SOUTHERN HILLS
P.O. BOK 391106
LA QUINTA CA 92253 ANZA CA'92539
(909) 76370645
WCC: STATE FUND
WC 1769754.
04/12./05
CSLB: 839.002.
05/31/05
CCC: C8 -C27 -C29-053
Permit . . . . . . BLDG -POOL
PERMIT
Additional desc .
Permit Fee. 180.00
Plan Check Fee
117.00
Issue Date
Valuation ..
17000
Qty Unit Charge Per
Extension
BASE FEE
45.00
15.00 9:0000 THOU
BLDG'2',001-25,000
135.00
Permit MECH
POOL
Additional desc .
Permit Fee . . .
24.00 Plan Check Fee-.
6:00
Issue Date . . . .
.Valuation
0
Qty Unit Charge Per
Extension
BASE FEE
15.00
1.00 9.0000 EA
MECH FURNACE <='100K
9.0;0
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
15.00
1.00 30.0000 EA
ELEC PRIVATE SWIMMING POOL
30.00
N
--- P.O. Box 1504.
78-495 CALLE TAMPICO � VOICE (760) 777-7012
LA QUINTA,'CALIFORNIA 92253 FAX (760) 777-7011
INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number:
Applicant: Date:Architect or Engineer:
Applicant's Mailing Address: Architect or Engineer's Address:
Lic. No.:
BUILDING PERMIT DECLARATIONS
I hereby affirm under persalt of LICENSED CONTRACTOR'S DECLARATION
y 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.
Date' Contractor
I hereby affirm under persalt of OWNER45UILDER DECLARATION
y 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).):
(--) 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 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 contractors) licensed pursuant to
the Contractors' State License Law.).
U I am exempt under Sec. . BA P.C. for this reason
Date Owner
1 hereby affirm under persaltof WORKERS' COMPENSATION DECLARATION
y 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:
Cartier Policy Number
_ I certify that, in the performance of the work for which this permit is issued, I shall not em to an
y person in anycompensation laws of California, and agree that, if I should become subject to the workers' compensation prorviisionsro Saection to become
7700 f the Labor Code. l shall
forthwith comply with those provisions.
Date 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:
1 hereby affirm under penaltyof CONSTRUCTION LENDING AGENCY
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
IMPORTANT Application is hereby made to the Director of Building APPLICANT
tdLICANT ACKNOWLEDGEMENT
Safety A
1. Each person upon whose behalf this application is made, each permit subject to the conditions and restrictions set forth on this application.
issued as a result of this application, the owner, and the applicant each agree twhose ea d shalluest l,, defendfor indemnity and hold hare benefit work is mless under
City of La Write.
ittspermit
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 dayt from date of issuance of such permit or
cessation of work for 180 days will subjecf permit to cancellation.
I certify that I have read this applicatiori and state that the above information is correct 1 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-mentionedro
p party for inspection purposes.
Date Signature (Applicant or Agent):
Page 2
Application Number 04-000047.93
Date 6/07/04
Permit .. PLUMBING
Additional desc .
Permit Fee .. 33.00 Plan Check Fee
8.25
Issue Date Valuation
0
Qty Unit 'Charge Per
Extension
BASE FEE
15.00
2.00 .6.0000 EA PLB FIXTURE
12.00
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
Special Notes and Comments
POOL/SPA. ALARMS/.BARRIERS SHALL BE IN
PLACE AT PRE -PLASTER INSPECTION..
EQUIPMENT ENCLOSURE NOT INCLUDED
,Fee summary Charged Paid Credited
Due
Permit Fee Total 282.00 .00 .00
282.00
Plan Check Total 142.50 .00 .00
142.50
Grand Total 424.50 .00 .00
424.50