10-0136 (BLCK)P.O. BOX 1504. VOICE (760) 777-7012
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA,•CALIF.ORNIA 92253 BUILDING & SAFETY DEPARTMENT INSPECTIONS.(760) 777-7153
= BUILDING -PERMIT
Date: 2/23/10 .
-Application Number: '�,_ 10 00000136 Owner:
Property Address: 54015 SOUTHERN HILLS CHANG ROBERDAS
APN: 775-101-033- - 54015 SOUTHERN HILLS
Application description: WALL/FENCE LA QUINTA, CA 92253
Property Zoning: LOW DENSITY RESIDENTIAL' (760)711-5500/'
Application valuation: 250
Contractor•� �..n. � r,•,� _.
:. F..B 2` i
Applicant: _ Architect or Engineer: C B R ENG CONTRACTOR f
50855 WASHINGTON STREE,ie--- e ��•_e_�
LA QUINTA, -CA 92253 - �'ds -r" •,'t sv?k)iP� gg
(760) 771-2278
Lic. No.: 504183
f x
—------—-------------------------------------------------------------—--———------------------------
LICENSED CONTRACTOR'S DECLARATION- WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of 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 and 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
License Class: A B -C33 - License No.: 504183 - - for by Section 3700 of the Labor Code, for. the performance of the work for which this permit is
1,�, 1 .� / /� issued.
;Date: Z"7,1_ N_ 'Contractor: I�()') '� �v L.¢zW ,,L eOG' �Qy/t �f& _ 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
OWNER -BUILDER DECLARATION insurance carrier and policy. number are:
I hereby affirm under penaltyof perjury that I am exempt from the Contractor's State License Law for the Carrier STATE FUND Policy Number 1542568-2009
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 l should become subject to the workers' compensation provisions of Section
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 3700 of the Labor Code shall fo th iPc ply w hh provisions.
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).: Date: `'Applicant:
(_ 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 or offered for sale (Sec. 7044, Business and Professions Code: The _ WARNING: FAILURE TO SECURE WORKERS' COMPENSATION 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 thework himselforherself through'his or her own employees, provided that the - .DOLLARS (5100,000). IM 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.
- 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
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(s) 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. , B.&P.C. for this reason - 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. -
Date: Owner: - 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
CONSTRUCTION LENDING AGENCY permit to cancellation.
• I -hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the I certify that I have read this application and state that the above information i Orrect. gree t mply with all
work for which this permit is issued (Sec. 3097, Civ. C.). - city and county. ordinances and state laws relating to buildin tructiOn, nd h re y au ori .representatives
of this county to enter upon the above-mentioned property f r ins ection rpos -
Lender's Name: �
]-Z_Date: _23- 6 .Signature (Applicant or Agent): -
" Lender's Address: ILL
LQPERMIT
LQ PERMIT
..Application Number
10700000136.
Permit . .
. WALL/FENCE PERMIT
-Additional desa
-Permit. Fee
15.00 Plan Check Fee
.00
Issue Date
Valuation . . .
. .250
Expiration Date
8/22/10
Qty Unit Chargee
Per
Extension
J
BASE FEE
15.00.1
------------------------------------------------------------------------------
Special Notes and
Comments
10 LN FT X 616" FT
HT BLOCK WALL PER
CITY STANDARDS & APPROVED
PLANS PER S.T.
Other Fees
. . . . . ._ BLDG STDS ADMIN (SB1473)
1.00
Fee summary..
-----------------
Charged Paid Credited
---------- --------------------
Due
Permit Fee Total
,----------
15.00 x.00 .00
15.00
Plan Check Total
.00 .00 .00
.00
Other Fee Total
1.00 .00 .00
1.00
Grand Total
16.00 .00 .00
16.00
LQ PERMIT
Bin #
Permit #
1 J
Project Address: _ '�
o
City of La Quinta
Bidding 8L Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quints, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet '
OP'ittr'S Name:
A. P. Number:
Address: i
Legal ion: ;�
'�ontctr:C
Address: ��55'eC, r ,% -�
City, ST, Zip:
Cit,,, ST, Zip: Z ,w
Telephone: 7
Project Description:
Telephone: i�� 2n
?
State Lic.# : O 3
City Lia #;
42
'
Arch., Engr•. Designer-
Address:
City, ST, Zip:
Telephone:
State Lic. #:
Name of Contact Person:
Construction Type: c5':
Project type (circle one): New Add'n Alter Repair Demo
Sq. Ft.: # Stories: # Units:
Telephone # of Contact Person:
Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW-THIS UNE
q
Submittal
Plan Sets
Req'd
Reed
TRACMG PERMIT FEES
Plan Cheek submitted Item Amount
Structural Cala
Reviewed, ready for correction Plan Cheek Deposit
Truss Cala.
Called Contact Person Plan Check Balance
Title 24 Calm
Plans picked up Construction
Flood plain plan
Plan resubmitted Mechanical
Grading plan
2'! Review, ready for correcfioamssue Electrical
Subeontactor List
Called Contact Person Plumbing
Grant Deed
Plans picked up S.M.L
H.O.A. Approval
Plans resubmitted Gradlug
IN HOUSE:-
''' Review, ready for correcdonsfissue Developer Impact Fee
i
Planning Approval
Called Contact Person A.LP.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees