0206-145 (CCOM)ch
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LICENSED CONTRACTOR DECLARATION'
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 0 (commencing with Section 7000) of Divislon 3 of the Business and
Professlonals Code, and my License is In full force and effect.
License # 11c, Class Exp. Dale
777699 H 04130/2(
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the properly, 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 & Professionals Code).
( ) I, as owner of the property, am exclusively contracting wish licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() 1 am exempt under Section , B&P.C. for this reason _
Date °;' Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and vall 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 370D of the Labor Code, for the performance of the work for which chis
permit is issued. W workers' compensation insurance carrJer & policy no, are:
Cart- PACIFIC EMPLOYEE: Policy No. WLR 043084:91.8
(This section need not be completed K the permit valuation is for $100.00 or less).
(- ) 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 should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil lines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each parson at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicator agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void If
work is not commenced within 160 days Irom date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation -
I certify that I have read this application and slate that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
B DING PERMIT PERkirrh
�QVALUATION ��Lo A T�� 30357
ADDRESS 52-990 EL DORADO RIVR a/7'270-002
APN
OVMER CONTRACTOR/USSIGNER[EN EER
TOLLBROTHERSINC TOLL BR INC
74.923 HOVELY LANE EAST . 2-220 92 HOVELY I ANE EAST S(ATEB-220
PALM DFSERT CA 92260 PALM DESERT CA 92260
60)67%49699//��//�� CB1Af� 3832
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USEOFPEFRAtrT VC
C014h ftCIAL
COM16fF.R. LkU 7,J00 SQ.FT. NIAINTENANCE FACILITY wl 1,20D
SQ,FT. CARPORT. H4 OCC. TYPE V -N SPRINKLER NOT& 
isaia4 rural buds imgwads bay wlcaaopy 1S NOT A PART OF TW5 f'P..Mr' 1C t
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QARAOE/CARPORT 1,200.00 SF
SPRINKLER. 7,700.00 SF
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AIC -- COMMERCIAL 1,340.00 SF
CONTRACT AMOUNT 33$,S60.OD LS
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ESTIMATED COST OF COMMUCIION
3990I0A0
PBRBW FEE SO)I+IMARY
CONSTRUCTION FEE 1011-000416-000 11,689,50
PLAN CHECK FEE 101-000439-318 $099.69
IBB DEPOSIT 101.000-439-318 -M.00
MECHANICAL FEE 101-000-421-000
ELECTRICAL FEE 101.000-420-000 !106.30
PLUMBINf1 FEE 101-000-419-000 =1i4.3D
STRONG MOTION FEE - COMM 100.000-241-000 183.79
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ORADINO FEE 101-000-423-000 =13.oD
DEVELOPER IMPACT FEE t1�,741.60
ART IN PUBLIC PLACES - COM1270-000-445-000 :1,993.OS
SUB TOTAL C013'STRUM701TAND PLAN CBWK
$21,252.13
IMS PRE -PAID FEL9
4750.00
TOTAL PERI W FEES DUE NOW
S20=.23
REiCE1Pi
DATE
ByDATE FINAIED
INSPECTOR
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