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04-5775 (BLCK).Taf 4 4 a" P.O. Box 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING PERMIT BUILDING & SAFETY DEPARTMENT (760).777-7012 FAX (760) 777-7011 INSPECTION REQUESTS (760) 777-7153 Application Number . . . . . 04-00.005775 Date Property Address . . . . . . '79883 DEREK ALAN DR APN: 649-630-024- - - Application description . . . WALL/FENCE Property Zoning . . . . . . . LOW DENSITY RESIfTIA Application valuation . . . . 390 UU Owner -------------------- BRETT JOHN 79883 DEREK ALAN DR LA QUINTA CA 92253 Contract o- - JUL 2 9 2004 - OWNER i CITY LA QUINTA 7/29/04 - ----=---------------------------------------------------------------------- Permit . . . . . . WALL/FENCE PERMIT Additional desc Permit Fee 15.00 Plan Check Fee .00 Issue Date . . . . Valuation 390 Qty Unit Charge Per Extension BASE FEE 15.00 7 -------------------------------------------------------------------- Special Notes and Comments 18 LF 5' GARDEN WALL EQUIPMENT ENCLOSURE PER CITY STANDARD Fee summary Charged Paid Credited Due •--------------------------------------------------------- Permit Fee Total 15.00 .00 .00 15.00 Plan Check Total . .00 00 _ .00 00. Grand Total 15.00 .00 .00 15.00 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: © T 7 �> I Date: ? - 75 -0Y - Applicant: DL N "n— Applicant's Mailing Address: 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 Code, and my License is in full force'and effect. License Class License No. Date OWNER -BUILDER 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).): Q 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 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.). 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 build or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to the Contractors' State License La U I am exempt under Sec.aicate his on Date Ow WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty ofowing declarations: _ I have and will mainnsent 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 0 I certify that, in the performance of the work for which this permit is iss d, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, d a ee that, if I should be me ubject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provi i ns. Date 7-2,1-bq Applicant WARNING: FAILURE TO SECUREWO ERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED HOUSA D DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR UEINThE ST, AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of pis 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 160 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 Ainat'ect. ply wi all city and countyordinances and state laws relating to building construction,,andhhereby authorize representatives of this ab entione ert for inspection purposes. DateJ c�- / —� Signature (Applicant or Agen