05-1691 (PLBG)P.O. Box 1504 VOICE (760) 777-7012
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number:
Applicant:
clya�
Applicant's Mailing Address:
. Date: 3- ZC5
Architect or Engineer:.
Architect or Engineer's Address:
Lic. No.:
BUILDING PERMIT DECLARATIONS
LICENSED CONTRACTOR'S DECLARATION
.tion 7000) of Division 3 of the Business and Professionals
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of pedury that I am exempt from the Contractors' State License Law for thelollowing 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 1, 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 thafthe 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 contractor(s) licensed pursuant to -
the Contractors' State License Law.).
U I 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 Secti�n 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 carder and policy number are:
Policy Number
I certify that, in the performanc�eof the work for whic his permit is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California, and agree t , if I should ome subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall
s prov,�
e Sio s.
forth comply with those provisions.
WARNING: FAILURE TO SECURE VVOP)<ERS'COMPE9tATXN COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED Ty0USAND DOLLARS4$1 00,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR COQE, INTEREST. AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of pedury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lenders Name
Lender's Address
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 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 inf . . ! la
ion is corr �g .
ormat _m�re ply with all city and county ordinances and state laws relating to building
construction, a d hereb authorize representatives of this cou ter upo above -m om
ed property for inspection purposes.
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Application Number .
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. . . .. 05-00001691
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Permit . . . .
PLUMBING
Additional desc
Permit Fee
36.75
Plan
Check Fee
3.75
Issue Date
Valuation
. . .
.
2500
Expiration Date
10/30/05
Qty Unit Charge
Per
Extension
BASE FEE
15.00
1.00 .3.0000
EA PLB
GAS PIPE 1-4
OUTLETS
3.00
5.00 .7500
EA PLB
GAS PIPE'>=5
3.75
1.00 15.0000
EA PLB
GAS METER
15.00
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Special Notes and Comments
--------------------------------
CONVERT FROM PROPANE
TO NATURAL
GAS PER
APPROVED PLAN/ISO.
Fee summary. 'Charged
--------
Paid
Credited
Due
----------
Permit Fee Total
----------
36.75
----------
.00
-----
.00
36.75
Plan Check Total
3.75
.00
.00
3-.75
Grand Total
40.50
.00,
.00
40.50
I