12-1262 (SOTB)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
T-4bt 4 4 Q"
ADDlicant:
Architect or Engineer: .
P /A -
BUILDING & SAFETY DEPARTMENT
• BUILDING PERMIT
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that?pm licensed under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Busines d Professionals Code, and my License is in full force and effect.
License Class: C29License No.: 95067
te: d o actor: /
OWN -BUILDER DECLARATION
1 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
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 10
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, 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.).
(_ 1 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:
BARRY MARRS
57355 INTERLACHEN
LA QUINTA,-CA 92253
Contractor:
L M MASONRY
+74074 ASTER -
PALM DESERT, CA 92260
(760)413-4030
Lic. No.: 966567
VOICE (760) 777-70 2
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
D /01
Date: 2 "'
OCT 2 3 2011
CITY OF ILA QUINTA
%Ip1A _
------------------- - - - - -- :
----------------
------
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 WMPT Policy Number EXEMPT
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 become subject to the workers' compensation laws of California,
and agree that, if I should a ome subject to the workers' co a sation provisions of Section
3700 of the Labor C d I all forthwith comply with thos provisions.
te: 23 7 pplicant:
WARNING: FAILURE TO SECURE WORKERS' COM ENSATION 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.
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 ab a information is correct. I agree to mply with all
city and co my ordinances and state laws relating to buildi c struction, and hereby authorize resentatives
of this my to enter upon th bove-mentioned prop inspection purposes.
�/23��Sij7 re (Applicant or Agent):
Application Number:
{12-00001 y�
Property Address:
57355 INTERLACHEN
APN:
762-180-006- - -
Application description:
STRUCTURES OTHER THAN BUILDINGS
Property Zoning: •
LOW DENSITY RESIDENTIAL
" Application valuation:
3200
ADDlicant:
Architect or Engineer: .
P /A -
BUILDING & SAFETY DEPARTMENT
• BUILDING PERMIT
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that?pm licensed under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Busines d Professionals Code, and my License is in full force and effect.
License Class: C29License No.: 95067
te: d o actor: /
OWN -BUILDER DECLARATION
1 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
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 10
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, 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.).
(_ 1 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:
BARRY MARRS
57355 INTERLACHEN
LA QUINTA,-CA 92253
Contractor:
L M MASONRY
+74074 ASTER -
PALM DESERT, CA 92260
(760)413-4030
Lic. No.: 966567
VOICE (760) 777-70 2
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
D /01
Date: 2 "'
OCT 2 3 2011
CITY OF ILA QUINTA
%Ip1A _
------------------- - - - - -- :
----------------
------
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 WMPT Policy Number EXEMPT
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 become subject to the workers' compensation laws of California,
and agree that, if I should a ome subject to the workers' co a sation provisions of Section
3700 of the Labor C d I all forthwith comply with thos provisions.
te: 23 7 pplicant:
WARNING: FAILURE TO SECURE WORKERS' COM ENSATION 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.
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 ab a information is correct. I agree to mply with all
city and co my ordinances and state laws relating to buildi c struction, and hereby authorize resentatives
of this my to enter upon th bove-mentioned prop inspection purposes.
�/23��Sij7 re (Applicant or Agent):
Application Number . . . . . •12-00001262
Permit BUILDING PERMIT
Additional desc .
Permit Fee . . . . 15.00 Plan Check Fee
9.75
Issue Date . . . . Valuation
384
Expiration Date 4/21/13
Qty Unit Charge Per
Extension
BASE FEE
15.00
PermitELEC-MISCELLANEOUS
Additional desc .
Permit Fee 18.00 Plan Check Fee
4.50
Issue Date Valuation . . .
. 0
Expiration Date 4/21/13
_
Qty Unit Charge Per
Extension
BASE FEE
15.00
4.00 .7500 PER ELEC DEVICE/FIXTURE 1ST 20
3.00
---------
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Special Notes and Comments
MASONRY TV STRUCTURE:-24 LF 36"
STRUCTURE INCLUDES 4 OUTLETS AND CABLE
TV CONNECTION. 2010 CODES.
----------------------------------------------------------------------------
Other Fees . . . . . . . . . BLDG STDS,ADMIN (SB1473)
1.00
ENERGY REVIEW FEE
.98
Fee summary Charged Paid Credited
--------------------
Due
-------------------------------------
Permit Fee Total 33.00 .00• 00
33.00
Plan Check Total 14.25 .00 .00
14.25
Other Fee Total 1.98 .00 .00
1.98
Grand Total 49.23 .00 .00
49.23
LQPERMIT
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATE BY
A
i
Bin. #
City of La Quinta
Building & Safety DivisiOn
Permit #
P.O. Box 1.504,"78-49S Calle Tampico
1a.Quinta, CA 92253 -:(760) 777-7012
Building
Permit Application and Tracking Sheet
Project Address: S 7fw
. f ICq 2 fjt/ ✓i �,�
A. P. Number.
Address: S7 .— 355'..�-may
i Legal Description:
City, ST, Zip: 0 u i �' f4 ZZ
Contractor. L.Y1'1 /✓) r}$1 N 2 Telephone:fst�'a�i�;ate%:.`'
Address:
Project Description: r-A A S V Kj
City, ST, Zip: l9 LtNI 0'l S'f R 44' 2-Z!. Gi U N %7 5T C7 N 4 V t N f
j Telephone: p
' cr< %r;•`• . \ g ;i r t
L ( N S
State Lic. #: ` G
City Lic. #..
Lt'
Arch., Engr., Designer.
Address:
City., ST, Zip:
Telephone:
�.
Construction Type:. Occupancy:
State Lic. #:
r
w kyiti4
Project type (circle one): New Add'n Alter Repair Demo
Name of Contact Person: Ly}
�.vl p L
Sq. Ft.: #Stories: #Units:
Telephone # of Contact Person:
_
O p
Estimated Value of Projt o d
ec
APPLICANT: DO NOT WRITE BELOW THIS UNE
# Submittal Req'dRecd
TRACMG PERMIT FEES
P(nn Sets
Plan Check submitted
Item Amount
i
Structural Calks.
Reviewed, ready for corrections
Plan Check Deposit.
'Fuss Calcs.
Called Contact Person
Plan Check Balance-
alance_Title
Tide24 Calks.
Pians picked up
Construction
--
Flood plain pinn_
-Piaas-resubmitted=—
—
Mechanical
- -
Grading plan
2� Review, ready for correctioWasue
Electrical
Snbeoatector List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.L
H.O.A. Approval
Plans resubmitted
Grading
IN ROUSE:-
s" ° Reviews ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
Pub. Wks. Appr
Date of permit Issue
School Fees
Total Permit Fees
... ..._...._ ._....... ... ... ...................