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04-6130 (RPL)BUILDING & SAFETY DEPARTMENT P.O. BOX 1504 (760).777-7012 78-495 CALLE TAMPICO FAX (760) 777-7011 LA QUINTA, CALIFORNIA 92253 INSPECTION REQUESTS (760) 777-7153 BUILDING PERMIT Application Number . . . . . X04=00006130 Date 9/01/04 Property Address 7-8-8-3-0-1S9—PALMA DR APN: 604-164-008-144 -23269 - Application description . . . POOL - RESIDENTIAL Property Zoning . . . . . . . LOW DENSITY RESIDENTIAL' Application valuation . . . . 28000 Owner Contractor CHRIS MENDELSSOHN f' INDIO HILLS POOL CONSTRUCTION 78830 LA PALMA DRIVE 28800 DESERT CHARM ROAD LA QUINTA CA 92253 DESERT -HOT SPRINGS CA 92241 (760) 275-840.0 WCC: STATE FUND WC: 1705281 11/01/04 CSLB: 816170 12/31/04 CCC: C53 ----------------------------------------------------------------------------- Permit . . . . . . BLDG PQbL PERMIT Additional desc Permit Fee _ 271.50 Plan Check Fee 176.48 Issue Date . Valuation . . . . 28000 Qty 'Unit..Charge Per Extension' BASE FEE 252.00 3.00 6.5000 THOU BLDG 25,001-50,000 �M1�Kw _ 19.50 14 - - - - - - - - - - - - - - - - - - - - - - - - - - - r - - - - - - - - - - - - -•J - - - - - - - - - 1- - - - - - - Permit . . . . . . MECH POOL Additional desc Permit Fee . . . 24.00.' Plan Check Fee 6.00 Issue Date -.�� , - _--Valuation 0 Qty - Unit''. Charge Per Extension - BASE FEE 15.00 1.00 9.0000 EA MECH FURNACE <=100K 9.00 -------------------------7-------------------------------------------------- Permit . . . . . ELEC POOL PERMIT -RES Additional desc . . Permit Fee . . . . 45.00 rP1•�� Ck Fjee 11.25 Issue Date . . . . UUluat0 Qty -Unit Charge Per SEP Q 3 2004 Extension BASE FEE 15.00 1.00 30.0000 EA ELEC PRIVATE S LP.©.OL!A 30.00 i 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: Applicant's Mailing Address: Date: Architect or Engineer: Architect or Engineer's Address: Lic. No.: BUILDING PERMIT DECLARATIONS 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 C and my Lice is is in full force and effect. _,_,11—cense Class qI— _ cense 0 OWNER191JILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractors' 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 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 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 or through his or her own employees, provided that the improvements are not intended or offered forsale. 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 protects 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: 1 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 Aof 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 ,sue wort Com sation ins carrier and policynum re: /Carrier S \ 1�� ��y�L�lLe icy Number f 0 2p I certify that, in the perTormance of the work for which th s permit is issued7 I- hall 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 workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. 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 ($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. 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 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, indemnity 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 hereby authorize representatives of this county to ter upon the above-mentioned property for inspection purposes. Date !A)gnature (Applicant or Agent): 3 1 Page 2 Application Number . . . . 04-00006130 Date 9/01/04 ---------------------------------------------------------------------------- Permit . . . . PLUMBING Additional desc Permit Fee 33.00 Plan Check Fee 8.25 Issue Date . . . . Valuation . . . . 0 Qty Unit Charge Per Extension BASE FEE 15.00 2.00 6.0000 EA PLB FIXTURE 12.00 1.00 3.0000, -EA PLB WATER INST/ALT/REP 3.00 1.00 3.0000.EA PLB GAS PIPE 1-4 OUTLETS ---------------------------------------------------------------------------- 3.00 Special Notes and Comments POOL/SPA. ALARMS/BARRIERS SHALL BE IN PLACE AT PRE -PLASTER INSPECTION. EQUIPMENT ENCLOSURE NOT INCLUDED Fee summary Charged Paid Credited ----------------- Due ------------------------------ Permit Fee Total 373.50 .00 .00 ---------- 373.50 Plan Check Total 201.98 .00 .00 201.98 Grand Total 575.48 .00 .00 575.48 3 1