12-0221 (BLCK)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Applicant:
I hereby affirm under penalty of perjury th*
Section 7000) of Division 3 of the Busines
- Licenstte CI s: B
�eJ �y � ontractor:
T4'19v 4 4 Q"
Architect or Engineer:
PIP(
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Owner:
DESERT CHEYENNE, INC.
78401 HIGHWAY 111, SUITE G "
LA QUINTA, CA 92253IU
(760)777-9920 !!
Contractor:
GJH DEVELOPMENT INC
27636 YNEZ ROAD C7 #151
TEMECULA, CA 92591
(760)578-3545
Lic. No.: 916227
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 3/12/12.
A;R L 4 2012- F
0" b..A u.4 r17: V•1�
;fir-.•:' _f.�x
3ED CONTRACTOR'S DECLARATION WORKER'S COMPENSATION DECLARATION '
licensed under provisions of Chapter 9 (commencing with - I hereby affirm under penalty of perjury one of the following declarations: -
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 No.: 916227 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
1 OWNER -BUILDER DECLARATION
Application Number:
12-00000,22i
Property Address: `-52313
WHISPERING WY
APN:
767-200-999-17 -312024-
Application description:
WALL/FENCE
Property Zoning:
LOW DENSITY RESIDENTIAL
Application valuation:
600
Applicant:
I hereby affirm under penalty of perjury th*
Section 7000) of Division 3 of the Busines
- Licenstte CI s: B
�eJ �y � ontractor:
T4'19v 4 4 Q"
Architect or Engineer:
PIP(
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Owner:
DESERT CHEYENNE, INC.
78401 HIGHWAY 111, SUITE G "
LA QUINTA, CA 92253IU
(760)777-9920 !!
Contractor:
GJH DEVELOPMENT INC
27636 YNEZ ROAD C7 #151
TEMECULA, CA 92591
(760)578-3545
Lic. No.: 916227
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 3/12/12.
A;R L 4 2012- F
0" b..A u.4 r17: V•1�
;fir-.•:' _f.�x
3ED CONTRACTOR'S DECLARATION WORKER'S COMPENSATION DECLARATION '
licensed under provisions of Chapter 9 (commencing with - I hereby affirm under penalty of perjury one of the following declarations: -
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 No.: 916227 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
1 OWNER -BUILDER DECLARATION
insurance carrier and policy number are:
I hereby affirm under penalty of perjury that I m exempt from the Contractor's State License Law for the
Carrier EXEMPT - Policy Number - EXEMPT
following reason (Sec. 7031 .5, Business and rofessions Code: Any city or county that requires a permit to
I certify that, in the perfor ante of the work for which 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 s a to become subject to•the workers' compensation laws of California,
permit to file a signed.statement that he or she is licensed pursuant to the provisions of the Contractor's State
and agree that, if I shou ecome subject to the workers' compensation provisions of Section
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
3700 of the Labor Cod I hall forthwith comply with those provisions..
%
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars 1$500).:
ate: / pplicant: -
(_) 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
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL -
Contractors' State License Law does not apply to an owner of property who builds or improves thereon,
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
. and who does the work himself or herself through his or her own employees, provided that the
DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN. _
improvements are not intended or offered for sale. If, however, the building or improvement is sold within
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
one year of completion, the owner -builder wilFhave 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 _ 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
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 Quima, its officers, agents and employees for anyact or omission related to the work being
performed under or following issuance of this permit.
2. Any permit issued as a result of this app ationbecomes null and void if work is not commenced
within 180 days from date of issuance such permit, or cessation of work for 180 days will subject
permit to cancellation.
I certify that I have read this application and state thLmation is correct. I agree to comply with all
city and county ordinances and state laws relating totion, and hereby authorize representatives
of this jcounA�to enter upon he above-mentioned pron purposes.
/Date: / 7 / S atura (Applicant or Agent):
Application Number . . . . . 12.-00000221
Permit .. ..". . . . WALL/FENCE PERMIT
Additional desc .
Permit Fee . . . . 17.00 Plan Check'Fee
.00
Issue Date Valuation
600
Expiration Date 9/08/12
Qty Unit Charge Per.
Extension `
BASE FEE
15.00
1.00 2.0000 HND BLDG 501-2,000
2.00
-- - -- --
Special Notes and Comments
-24 L.F. GARDEN WALL, CITY STANDARD @
SIDE P/L (RETURNS) 2010 CODES.
-------------------_------------------------------------------
Other Fees . . . . . BLDG STDS ADMIN (SB1473)
-----_--------
1.00
Fee summary .Charged Paid' Credited
Due
Permit-Fee Total 17.00 .00
.00
17.00
Plan Check Total .00 .00
.00
.00
Other Fee Total 1.00 .00
.00
1.00
Grand Total 18.00 .00
.00
18.00
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APPR®VE
i FOR CONSTRUCTION
DATE 3 /2-11Z, BY c
1'
Bln #
of,, ::QuIn ...
:. Building 8z Safety Division
Q.O. Box 150.4j,'78-495 Calle Tampico ,
14.Quinia, CA 92253 -:(760) -777-7011
Building Permit Application and Tracking. Sheet
Permit #.
�.�
a-'
Project Address:.
er's Name:.
A. P. Number.
Address:
Legal Description: ,
Contra
City, ST, Zip;
Telephone: `
Address:'' (�
Project Description: ALI
City, ST, Zip:
; y
Telephone: n. NOW
/adl O
Staab Lic. #: City Lie. #;
Arch., Engr., Designer.
Address:
City, ST. Zip:
Telephone: Y' '
State Lic. #:
Name of Contact Person
Construction Type:. Occupancy:
project type (circle one): New Add?n Alter Repair Demo
Sq. Ft.: # Stories: # Units:
Telephone # of Contact Person.
Estimated Vahie of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
M
Submittal
Req'd
Recd
TRACMG
PERMIT FEES
Plan Sets
Plan Cheek submitted
Item Amount
Structural Cales.
Reviewed, ready for corrections
Plan Cheek Deposit. .
Truss Calcs.
Called Contact Person
Plan Cheek Balance
Title 24 Calci.
Plans picked up
ConstracIon
Flood plain plan
Plans resubmitted..
Mechanical
Giading plan
2' Review, ready for correctionstiissue
Electrics:
Subcoutactor List
Called Contact Person
Plumbing
Grant Deed
Pians picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading-
M HOUSE:
'rd Review; ready for correctionstissae
Developer Impact Fee
Planning Approval.
Called Contact Person'
A.LP.P.
Pub. Wks. Appr '
Date of permit issue
School Fees
Total Permit Fees