05-5449 (BLCK)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
Property Address:
APN:
Application -description:
Property- Zoning:
Application valuation:
t
Applicant:
05-00005449
57750 TROON WY
762-360-006- -
WALL/FENCE.
LOW DENSITY RESID
3800
An
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
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: C29 License No.: 649905
$ate: 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 applicariffor 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 CodO or.
h 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).:
(_ 1 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 oroffered 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 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 whobuilds or improves thereon, and who contracts for the projects with a contractor(s) licensed
pursuant to the Contractors' State License Law.). -
(_ 1 I am exempt under Sec. , B.&P.C. for this reason li
Date: Owner: -
-- - - CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lendingagency 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: 12/14/05
Owner:
SOUTHERN HILLS DEVELOPMENT
55161,SOUTHERN HILLS
LA QUINTA, CA 92253
Contractor:
SABOR MASONRY
41625 ECLECTIC STREET, #M-1
PALM DESERT, CA 92260
(760)674-0666
Lica No.: 649905
------------------
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.
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 STATE FUND Policy Number 0026187
certify that, in the performance of th work for w ich this permit is issued, I shall not employany
person in any manner so as to be me subject t workers' compensation laws of California,
and agree that, if I should beco ubject tote work ' compensation provisions of, Section
3700 of the Labor Code, I sh ort y w ose provisions.
1at8: / / O Applican/Z'
WARNING: FAILURE TO SECUREORKERS' 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 Quints, 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 inspection purposes.
Date: Signature (Applicant or Agent): '
Application Number . . . . . •05-00005449
Permit WALL/FENCE PERMIT
Additional-dese .,
Permit Fee 63.00
Plan Check
Fee
:00
Issue Date . .
Valuation
3800
Expiration Date 6/12/06
Qty Unit Charge Per
Extension.
BASE FEE
45.00•
. 2.00 9.0000 THOU BLDG 2,001'-251000
18.00
--------------------
Special Notes and Comments
152 L. -F. 6•' BLOCK WALL, ORCO SYSTEM.
Fee summary Charged Paid
Credited
Due
Permit Fee Total 63.00
.00
.00
63.00
Plan Check Total .00
.00
.00
.00
Grand Total 63.00
00
00
63.00
LQPERMIT
;f
-a%