12-1258 (BLCK)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:' 12,0 001258 %
Property Address: 52535 HUMBOLDT BLVD
APN: 767-200-091-19 -34968 -
Application description: WALL/FENCE
Property Zoning: LOW DENSITY RESIDENTIAL
Application valuation: 7400
Tu!t 4 a(P Q"
Applicant: Architect or Engineer:
------------------
LICENSED CONTRACTOR'S DECLARATION
BUILDING & SAFETY DEPARTMENT
.BUILDING PERMIT
1 hereby affirm under penalty of perjury that I am lic under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Pro s nals and my License is in full force and effect.
Li c nse Class: B L' ense : 915336
Dater0 3rr� ntractor:
OWNE - UILDER DECLARATION
I hereby affirm under penalty of perjury that I am exam t rom the Contractor's State License Law for the
following reason (Sec. 7031.5, Business and Professio ode: Any city or county that requires a permit to
construct, alter, improve, demolish, or repair any struct , prior to its issuance, also requires the applicant for the
permit to file a signed statement that he or she is licens 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
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
(_ 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
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, 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—) I am exempt under Sec. , B.&P.C. for this reason
Date:
Owner:
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:
EAST OF MADISON LLC
PO BOX 1482
LA QUINTA, CA 92247
Contractor: D
DBCA INC
P.O. BOX 1482
LA QUINTA, CA 92 4)
(760)393-5271
Lic. No.: 915336
VOICE (760) -' 2
FAX (760) -701.1
INSPECTIONS (760) 777-7153
Date: 10/23/12
u .
I i
70f7_131 2011
WORKER'S 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 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 TRAVELERS Policy Number YJUB282D7797-12
_ I certify that, in the performance o the work for which this permit is issued, I shall not employ any
person in any manner so as ecom ubject to the workers' compensation laws of California,
and agree that, if 1 should be a sub ec a workers' compensation provisions of Section
3700 of the Labor Code, I s ith comp with those provisions.
"."Jo,-fz../.r"ant
WARNING: FAILURE TO SECURE WORKERS'MPENSATION COVERAGE IS UNLAWFUL, AND SHALL
MINAL
SUBJECT AN EMPLOYER TO CRIPENA ES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($100,000). IN ADDITION TO.THE ST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
ODE
SECTION 3706 OF THE LABOR C, INTER , 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 Lto
abovApio
L�Qnis correct. I agree to comply with all
city and county ordinances and state laws reing ceby authorizerepresentatives
of thi countyto enter upon eabove-mentiy for ies.
ate: V� (.�S' nature (Applicant or
Application Number . . . . . 12-00001258
Permit . .
. WALL/FENCE PERMIT
Additional desc .
Permit Fee . . .
. 99.00
Plan Check Fee
.00 -
Issue Date . . .
.
Valuation . . .
. 7400
Expiration Date
4/21/13
Qty Unit Charge Per
Extension
BASE FEE
45.00
6.00 9.0000 THOU BLDG 2,001-25,000
54.00
----------------------------------------------------------------------------
Special Notes and
Comments
TOTAL OF 296 L.F.
6' GARDEN WALL AT
SEVERAL LOCATIONS
ON PROPERTY, CITY
STANDARD. 2010 CODES.
-----------------_-_------------------------------
Other Fees .
. . . . . . BLDG STDS ADMIN (SB1473)
1.00
Fee summary
-----------------
Charged Paid
--------------------
Credited
--------------------
Due
Permit Fee Total
99.00
.00 .00
99.00
Plan Check Total
.00
.00 .00
.00
Other Fee Total
1.00
.00 .00
1.00
Grand Total
100.00
.00 .00
100.00
LQPERMIT
sin.#
Citj/ Of La Quintd
Building 8i Safety Division
P.O. Box 1504,78-495 Calle Tampico
ia.Quinta, Cao 92253 • (760) 777-7012
Building Permit Application'and Tracking Sheet
Permit #
1�
Project Address: �`- �57� /'�/i Owner's Name:.
A. P. Number: Address:j f` AAV
Legal Description: City, ST, Zip:
1Ji,� "Al • '•
Contractor: Telephone:.;=-5��;,
Address: Project Description:
City, ST, Zip: �` 47/�' 9?i2�`jj "' , Z� Al -d
Telephone• �2 !�' '� 'per ms M —..._
State Lic. 4: Q City Lic. #: 't/ J 3 3
Arch., Engr., Designer: �
n I 105-7 4VIAWL P,e, .
Address: l`"'
City., ST, Zip:
Telephone: Construction Type: . Occupancy:
State Lic. #: � rV ' Project type (circle one): New Add'n Alter Repair Demo
Name of Contact Person: �%Ojr . Sq.'Ft.: # Stories: #Units:
Telephone # of Contact Person: .�� Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Recd
TRACMG
PERMIT FEES'
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit. .
'Fuss Calcs•
Called Contact Person
Plan Check Balance
Title 24 Calcs
Plans picked up
Construction '
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2id Review, ready for correctionsrmue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S•M,I,
H.O.A. Approval
Plans resubmitted
Grading
IN ROUSE:-
'^' Review; ready for correctionslissue
Developer Impact Fee
Planning Approval.
Called Contact Person
A,I,P,P,
Pub. Wks. Appr
Date of permit issue
School Fees '
Total Permit Fees
UM