05-1978 (PLBG)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: W65Z0V0_0_1T9,7:8
Property Address: 78810 SUNBROOK LN
APN: 604-291-001-1 -23995 -
Application description: PLUMBING
Property Zoning: LOW DENSITY RESIDENTIAL
Application valuation: 170 -
Applicant: Architect or En
4
BUILDING & SAFETY DEPARTMENT
. BUILDING PERMIT
MAY 2 3 2005.
r:
CITY OF LA QUINTA
FINANCE DEPT.
Owner:
PETRI RICHARD F
Jj3010
.WN+R#&WN, CA 91r"9
Contractor:
FOY, SCOTT A.-
79-499 COUNTRY CLUB DR STE 9
INDIO, CA 92201
(760)360-0927
Lic. No.: 828264
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 5/23/05
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LICENSED CONTRACTOR'S DECLARATION
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty ofL perjury that I am licensed under provisions 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 a . nd Professionals Code, and 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,
LicenseClass: C36 nseNo.: 828264
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is -
�Contraictov
issued.
a
KI I h ve and will maintain workers' com pensation insurance, as required by Section 3700 of the Labor
�. �,.-.UILDER
Code, for the performance of the work for w hich this permit is issued. My workers' compensation
DECLARATI ON
insurance carrier and policy number are:
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law f or the
Carrier STATE FUND — Policy Number 1576840
following reason (Sec. 7031.5, Business and Professions Code: Any city or county that requires a permit to
I certify that, in the performance of the work for which this permit is issued, I shall not employ any
construct, alter, improve, demolish, or repair 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 or she is licensed pursuant to the provisions of the Contractor's State
and agree that, if I should be;cirnegbjeje workers' compensation provisions of Section
`0 su
License Law lChapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
of the Lab , Code, I shal rth with those provisions.
1 fo wipc "Y
that he or.she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
;3F70O
any applicant for a permit subjects the applicant to a civil penalty tif not more than five hund red dollars ($500).:
a�n
P"c t.
1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and
�W�SATION
the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The
WARNING: FAILURE TO SECURE WORKERS. COVERAGE 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 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 or improvement is sold within
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
Date:
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, 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 thireon,.an�d who contracts for the projects with a contractor(s) licensed
pursbant to the Contractors' State License Law.).
I am exempt under Sec. , B.&P.C. for this reason
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: IA
LQPERA11T —
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.
I . 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 Quinta, 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 herebW_"orize representatives
of th* -mentioned prope
"� :� y to �enter upon t above
Date Signature (Applicant or Agent):
Application Number . . . 05-00001978
Permit' PLUMBING
Additional desc-
Permit-Fee, 22.50
Plan Check Fee
.00
-Issue Date
Valuation . . .
.
0
Expiration Date 1:1 19 0*5
Qty Unit*Charge Per
Extension
BASE
FEE.
15.00
1.00 7.5000 EA PLB WATER HEATER/VENIT
7.50
------------------ ------------------ ---------
Special Notes and Comments
7 ---------------------------7---
WATER HEATER CHANGE -OUT
Fee summary Charged
----------------- ---- ------ ----------
Paid Credited
-------- ----------
-,Due
7
Permit Fee Total 22.50
7-
.00 -�00
22.50
Plan Check Total .00
.00 .00
.00
'Grand Total 22.50
.00 .00
22.50
LQPERMIT