05-4992 (BLCK)ill
P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: 05-00004992
Property Address: 50455 WOODMERE
APN: 772 -040 -022 -
Application description: WALL/FENCE
Property Zoning: LOW DENSITY RESIDENTIAL
Applioation 'valuation: 620
Applicant:
Tavl °F 4 Q"
Architect or Engineer:
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that Iam 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: C29 LicenseNo.: 370756
Date: Contractor:
OWNER -BUILDER DECLARATION .
1 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, 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.).
�< 11 I, as owner of the property, am exclusively ntracting with licensed contractors to construct the project (Sec.
7044, Business and Professions Code: ontraaors' State License Law does not apply to an owner of
'property who builds or improves thereontfh ho contracts for the projects with a contractor(s) licensed
pursuant to the Contractors' State Licens.
1 _) I am exempt under Sec. I P.C. reason
Date: 44 ! Owner:
CONST CTION LENDING AGENCY
hereby affirm under penalty of perjury that there is a c nstruction 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
Owner:
JOHN PEDALINO
50455 WOODMERE
LA QUINTA, CA 92253
(760)578-6915
Contractor:
PULLIAM MASONRY COM
1569 NANDINA AVENUE
PERRIS, CA 92571
(951)940-4441
Lic. No.: 370756
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 11/10/05
JOHN
B 22,05 �Lu
L
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 performai a of the work for which this permit is issued. My workers' compensation
insurance carrier and p' I y umber are:
Carrier STATE FUND Policy Number 1572567
�.I certify that, in the perfora of the work for which this permit is issued, I shall not employ any
person in any manner so a t become subject to the workers' compensation laws of California,
and agree that, if I shoul become
subject to the workers' compensation provisions of Section
3700 of the Labor Code, II forthwith comply with those provisions.
Dated ni v,,. Applicant:
WARNING: FAILURE TO SECURE WOR/NS' S' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS 1$100,0001. 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 urider or following issuance of this pe it.
2. Any permit issued as a result of this appJbuildings
null and void if work is not commenced
within 180 days from date of issuance or cessation of work for 180 days will subject
permit to cancellation.
I certify that I have read this application and state thrmation is correct. I agree to comply with all
city and county ordinances and state laws relating touction, and hereby authorize representatives
of thiy to enter upon the above-mentioned prction purposes.
Da: . iA Q �' Signature (Applicant or Agent):
Si
9
LQPERMIT
Application Number . . . . . 05-00004992
Permit . .
. WALL/FENCE PERMIT
Additional desc .
Permit Fee . . .
. 19.00
Plan Check
Fee
.00
Issue Date
Valuation
. . .
. 628
Expiration Date..
5/09/06
Qty Unit Charge Per
Extension
BASE
FEE
15.00
2.00 2.0000 HND BLDG
501-2,000
4.00
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' Special Notes and
Comments
TOTAL OF 29 LF 5'
BLOCK WALL AND
3
GATES PER APPROVED PLAN. CITY STANDARD.
Fee summary
---------
Charged
--------------------
Paid Credited
----------
----------
Due
--------
Permit Fee Total
19.00
.00
.00
19.00
Plan Check Total
.00
.00
.00
.00
Grand Total
19.00
.00
.00
19.00
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATEILo_ BY
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