05-4141 (PLBG)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
05-00004141
Property Address:
53666 AVENIDA� VALLEJO .
APN:
774-123-009-16 -000000-
Application description:
PLUMBING
Property Zoning:
COVE RESIDENTIAL
Application valuation:
7000
T 4bf 414Q11;1tlhAl'
VOICE (760) 777-7012
FAX (760) 777-7011
BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: 9/15/05
Owner:
SHARYL KUEHNERT
53666 AVENIDA VALLEJO
LA QUINTA, CA 92253
---------------------------------
Applicant: Architect or Engineer:
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.:
Date: Contractor:
OWNER -BUILDER DECLARATION
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 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 forthealleged 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.).
(_ I I, as owner of the property, am exclusively contracting with Ii ensed contractors to construct the project (Sec.
7044, Business and Professions Code: The Contractors tate Lice �a Law does not apply to an owner of
property who builds or improves thereon, and who Copt Cts for a projects with a contractor(s) licensed
pursuant to the Contractors' State ense taw -7/ - - --
1 _ 1 I am exempt under Sec. .&P.C. fort is reaso
Date:
Owner:
I hereby affirm under penalty of perjury that
work for which this permit is issued (Se
Lender's Name:
Lender's Address:
ONSTRUCTION LENDING AGENCY
is aconstruction lending agency.for the performance of the
Civ. C.).
LQPERMff -
Contractor:
Owner
-
--------- - - - -
- -----Jv--1- - "---
� ��05
----------- - -
-�-�
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations: -
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 workerscompensation 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' Policy Number
_ I certify that, in the performance of the woWwhich rmit is issued, I shall not employ any
person in any manner so as to become skers' compensation laws of California,
and agree that, if I should become subjecompensation provisions of Section
3 00 jthe Labor Cod hall�ort witse provisions.
Date:03 APPlicant: -
WARNING:' TO SECURE W05K RS' COMP NSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMI PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($100,000). IN ADDI ON TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABO 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 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 aresult of this application becomes null and void' oak is not commenced
within 180 days from date of issuance of such permit, or cessatio f w7k for 180 days will subject
permit to cancellation.
I certify that I have read this application and state that the abovjif matio is cor�rect. I agree to comply with all
city and county ordinances and state laws relating to 'ding co Vreby authorize representatives
of this cou y to (nite`r upon the above-mentioned p party r r
Date: v $i/gnature (Applicant or Agent):
Application Number
. . . . . 05-00004141
Or
Permit. • .
PLUMBING SEWER
Additional. desc .
Permit"Fee . . .
. 30.00
Plan Check
Fee
.00
."Issue Date
Valuation
. . .
. 7000_
". Expiration -Date
3/14/06
Qty Unit Charge Per,
Extension"
BASE" FEE
30.00
Fee summary
Charged Paid
Credited
Due
Permit Fee Total
30.00
.00
.00
30.00
Plan'Check Total
00
.00
.00
.00
Grand Total
30.00
.00
.00
30.00
r
• LQPERMIT
HAMMER PUMPING INC. JOB INVOICE
P.O. Box 2448
CATHEDRAL'CITY, CALIFORNIA 92235-2448
�71CM ?Cn 7AAC
(760)321-7448
(760) 321- 7448
760) 321 . 448
CUSTOMER'S ORDER NO.
A�E ORDERED
T-2-7 , 05 -
ORDER TAKEN BY
DATE PROMISED ❑ A.M.
Gallons
❑ P.M.
614ZO QQ (
6 1
PHONE
ADDRESS
MECHANIC
\ (lam
CITY
Dumping Fee per 1000 gal.
HELPER
-JOSITT-ME AND LOCATION
io{pip A�
\ C )
L ..
❑DAY WORK
ESCRIPTION OF WORK
(�
1!
t
� X -
❑CONTRACT
'
�0 EXTRA
Out of Area Fee
CC
Locating / Opening Fee (per hour)
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
Gallons
Z
Pumping Fee per 1000 gal.
Dumping Fee per 1000 gal.
,r
Out of Area Fee
Locating / Opening Fee (per hour)
Size System:
A SERVICE CHARGE OF $20 WILL BE DUE
ON ALL RETURNED CHECKS.
18% PER YEAR WILL BE CHARGED ON
PAST DUE ACCOUNTS OVER 30 DAYS. '
HOURS
LABOR AMOUNT
TOTAL
MATERIALS
MECHANICS Qa
HELPERS Q
TOTAL
LABOR
I hereby acknowledgedhe satisfactory
comp letion,oi the�bovek described work:
TOTAL LABOR
w
TAX
SIGNATURE f � /
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DATE 11 L/ <y
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