05-2392 (DSF)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
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BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Application Number: 05,00002392 Owner:
Property Address: 56340 JACK NICKLAUS EILERS HENRY G
APN: 762-070-032- - -
Application description: DEMO - SINGLE FAMILY
Property Zoning: LOW DENSITY R - -�ENTIAL
Application valuation: 0
Contractor:
Applicant: D A ct or Engineer: EDWARDS CONSTRUCTION, BOB
51455 DESERT CLUB DRIVE
LA QUINTA, CA 92253
-8202
AF�c��1€�'fp Lic. No?8
:684857
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 BUSt�es,s nd Professionals Code, and my License is in full force and effect.
Licensedassl B I / �/� �. LicenseNo.: 684857
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
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 _ 1 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. , BAP.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
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 6/16/05
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 VIRGINIA SURETY Policy Number 00500027012
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 Id become s blect to the workers' compensation provisions of Section
3700 of the Labor Cod , I it omply with t se provisions.
Date: ( Applicant: _
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.
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.
certify that I have read this application and state the th above i f correct. I agree to comply with all
city and ou y ordinances and state laws relating t bu' in con r on, hereby authorize representatives
of this cNCR
er upon the above-mentioned p p in pu po es.Date: Signature (Applicant or Agent):
`
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Application m�nr . ' . . ' O5-O�002 90
Permit . . . . ' . DEMO PERMIT
Additional deac
Permit Fee . . . - 45.00
Plan Check
Fee '
' .00
Issue Date . . . '
Valuation
, . .
' O
` Expiration Date . ' 12/1j/05
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Qty Unit Cbazge Per
. Extension
- BASE Foo
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45.00
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---,-------- --- --- �--------_-_--_----
Notes and Comments '
-------
-----------~------
.Speoial
DEMO 32 Ln {AzDom WALL IN pREsmRxrI0m
FOR REMODEL Z»xPIANCHECK.
Fee summary Charged Paid
----------------- ---------- --- ------
Credited
---------- ------^---
Due
Permit Fee Total ' 45.00
.Oo
.00
45.00
Plan Check Total .00
.00
.00
.00
Grand Total 45.0O
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.00
'OU
45.00