05-2389 (SPIN)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
Property Address:
APN:,
Application description
Property Zoning:
Application valuation:
Applicant:
05-00002889 .
-78'775 DULCE DEL MAR
643-100-035-190 -26152 -
SPECIAL INSPECTION .
LOW DENSITY RESIDENTIAL
0
Architect or
T4&t aF4w
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
D °
M 163 2005 11
1A
Owner:
TREVISANI, MARJORIE & JOSEPH
78775 DULCE DEL MAR
LA QUINTA, CA 92253
Contractor:
Owner
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 6/16/05
-----------------------------------------------
LICENSED CONTRACTOR'S DECLARATION -
---
----------------------------------------------—
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury that 1 am licensed under provisions of Chapter 9 (commencing with
I hereby affirm under penalty of perjury one of the following declarations:
Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect.
_ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided
License Class: License No.:
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
issued.
Date: Contractor:
_ 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
OWNER -BUILDER DECLARATION
insurance carrier and policy number are:
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the
Carrier Policy Number '
following reason (Sec. 7031.5, Business and Professions Code: Any city or county that requires a permit to
_ I certify that, in the performan f the work for whi this permit is issued, I shall not employ any
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the
person in any manner o become subject to he workers' ensation laws of California,
permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State
r f
and agree that ifo become subject to the orkers' c pe atprovisions of Section
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
3700 the L C I shall fo hwith comply th a visions.
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).:
t
��/ant. �'
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 I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.
7044, Business and Professions Code: The Contractors' St a License Law does not apply to an owner of
property who builds or improves thereon, and ho contra s for the projects with a contractor(s) licensed
pursuant to the Contractors' State License w.).
i�l�l am exempt under Sec. 4B.&P. r this reason
ng
l/- CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of per/ec.
t there is a construction lending agency for the performance of the
work for which this permit is issued097, Civ. C.).
Lender's Name:
Lender's Address:
LQPERMIT
YEARNING: FAILURE TOS URE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYEFyTO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($100,000)/.N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OFT E 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 an oid if work is not commenced
within 180 days from date of issuance of such permit, or ce _tion of work for 180 days will subject
permit to cancellation.
I certify that I have read this application hat the above infor _tion is correct. I agree to comply with all
city and county ordinances and stat r g to building con do and h authorize representatives
his county to enter upon the abo'ra tion grope for inspec o purp
dwl� L O Alnna
LQPERMIT
Application Number . . . . . 05-00002389
Permit SPECIAL INSPECTION
Additional desc .
Permit Fee . . . . 100.00 Plan Check
Fee
.00
Issue Date . . . . Valuation
. . .
. 0
Expiration Date . . 12/13/05
Qty Unit Charge Per
Extension
BASE FEE
-------------------------------------------------------------------------
100.00
----
Special Notes and Comments
SPECIAL INSPECTION/EXPIRED PERMIT#14235
FOR 315 SF ROOM ADDITION.
{
Fee summary Charged Paid Credited
Due
------ 7 ---- ----------
Permit Fee.Total 100.00 .00
----------
.00
100.00
Plan Check Total' .00 .00
.00
.00
Grand Total. 100.00 .00
.00
100.00