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05-2466 (PLBG)P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: Property. Address: APN: Application description Property Zoning: Application valuation: Applicant: llgosA000. - 5_1'G15 JA CALLE C_ , BA lT70--rG5-U-14-3 6-6-0000- PLUMBING MEDIUM DENSITY RA 1800 Architect or Engineer ----------------- LICENSED CONTRACTOR'S DECLARATION BUILDING & SAFETY DEPARTMENT BUILDING PERMIT D SUN 2 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 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 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 for the alleged exemption. Any violation of Section 7031.5 by ant applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars 155001.: j 1 _) 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and l 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.). (_ 1 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.). (_) I am exempt under Sec. Bf&P.Cnfor this reason��� 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: LQPERMIT Owner: HICKS ELI/WANDA 51315 CALLE JACUMBA LA QUINTA, CA 92253 actor: r VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 WORKER'S COMPENSATION DECLARATION Date: 6/20/05 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 Policy Number . I certify that, in the performance of the work for which this 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 that, if I should become subject to the orkers' ation provisions of Section 3700 of the Labor CDA, A shall forthw'(h comply its ose provi ions. WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS 1$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 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 buildin4 construction, and herebyhuthori;�at7resentatives of this county to enter upon the above-mentioned propf(rtl f r inspertion purposes/,. / � Application Number . . . . . 05-00002466 Permit . . . PLUMBING SEWER Additional desc . Permit Fee . . . . 30.00 Plan Check Fee .00 Issue Date . . . . Valuation . . . . 1800 Expiration Date 12/17/05 Qty Unit Charge Per Extension BASE FEE 30.00 -------------------------------------------------- Special Notes and Comments ------------------------- SEWER CONNECT/SEPTIC ABANDONEMENT 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 LQPERMIT :calved From: ldress: � :count No. :rvice Address Meter(s) COACHELLA VALLEY WATER DISTRICT CASH RECEIPT -DETAIL N2 .80738 Backflow(s) House Lateral(s) Detector Check(s) Meter Surcharge 'Sanitation Capacity Charge �S, W.S.B.F.C. Temporary Construction Meter Turn on Charge _ Uncollected Account - Name Inspection Fee- Tract - Fee - Plan Check Fees Water / Sewer - Tract - Bond Payment - A.D. - Bond Assmt. Customer Deposit Other 9 � 5 DO TOTAL $ Remarks: �y to: (,� LJi X20 S ?, :ash �35� Water Service :heck Aoney Cashier ')rder CMD -4386"(111189) r _. _... _.... WILLIAM THOMAS BUFFIN 5358 ' MICHELLE RAE EICHSTEDT DATE DETHE ORDER C I ORLIEOF v $ ' T/ 471' f 7 (/t� L e ��r/ D LARS0 s.<..ur ...wn. o�. aa. j Be VALLEY INDEPENDENT BANK 51-290 Avenida Bermudas, La Quints, CA 92257 1 00.9426222 FOR ONARIAND