05-3830 (PLBG)P.O. BOX -1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
Property Address:
APN:
Application description
Property Zoning:
Application valuation:
Applicant:
WO -5-10-0-0-03B.3.02
54205 AVENIDA VILLA
7747223 -029 -ST -000000-
PLUMBING
COVE RESIDENTIAL
400
Tjht .4 4 Q"
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Architect or Engineer:
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 Profession ode, and my License is in full force and effect.
License Class: -A icens 269354
ate:ntractor:
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of penury 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 _—) 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 ISec.
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 I am exempt under Sec. , B.&P.C. for this reason
t
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: wl
Lender's Address: ry
J
LQPERMIT
J
Owner:
MOODY GAYLENE M
5220 SALISBURY CIR
LA PALMA, CA 90623
Contractor:
COVEY 1140, II D
309 E COMMERCIAL.STREET
POMONA, CA 91767
(909)623-2502
Lic. No.: 269354
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
------------------
WORKER'S COMPENSATION DECLARATION
Date: z 8/30/05
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 performance of the work for which this permit is issued. My workers' compensation
insurance carrier and policy number are:
Carrier STATE FUND Policy Number. 919237
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 subjec t the workers' compensation provisions of Section .
3700 of the Labor Code, I shall fort com ly with those provisions.
,otlate: •� A'p
WARNING: FAIL RE TO SEC IR ORKERS' 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 Ouinta, 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 180 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 ab a info r ation is correct. I agree to comply with all
city and county ordinances and state laws relating to buildi constr tion, and hereb representatives
of thi�sAountty to enter upon th ove-mentioned propert for ins coon purpose _
�y �" nature (Applicant or Agent):-�
Application Number . . . .05-00003830
Permit . . . PLUMBING
Additional desc .
Permit. Fee .. 22.50
Plan Check Fee
.00 -
Issue Date.
...".Valuation
; 0
Expiration Date 2/26/06
•.
Qty Unit Charge Per.
Extension
BASE
FEE
15.00
1.00 7.5000 EA PLB WATER HEATER/VENT
7.50'
---------------------------------------_-----
Special Notes and Comments
'WATER HEATER CHANGE OUT
Fee summary" Charged
Paid Credit(Cd
Due
Permit.Fee Total 22..50
----------------.-----
.00" .00
22.50
Plan Check Total .00
:00 .00
.00
Grand Total 22.50
.00 .00
22.50
. ' LQPERMIT
Bin #
City Of La Qu & to
. Building & Safety Divisicn .
Permit #4 P.O. Box -1504,-78-495 Calle Tampieo
�La Quinta, CA 92253 - (760) 777-7012
3 Building Permit Application and Tracking Sheet
Project Address: \
�� �J�111J l �_1 Owner's Name: Y �� a t �, , c ...r (n, r-,
A. P. Ndmber:
Legal Description:
Contractor: �( �j� C �v
Address: W #
1�pll_� L
City. ST. Zip: Y_ C q l nJ 6. CA
Telephone:
x
b
Z
6
3
State Lic. # City Lic. #:
Arch., Engr.. Designer:
Address:
City, ST, Zip:
Telephone:
Address- X
City, ST, Zip: K
®o t _JT- .
Telephone:
Project Description: C/�
Construction Type: Y
P:
Oc�
cuPc
an v.
to
S to•
Ltc. #•
0J
ect
type (circle r
cle
on
e6:
New
Add'n Alter
Repair Demo
Pr
Name of Contact Person:
V q. Ft.: #Stories: #Units:
Telephone # of Contact Person.• t)�Al'
# Submittal.
Plan Sets
Structural Gales.
Truss Calcs.
Title 24 Calcs.
Flood plain plan
Grading plan
Subcontactor List
Grant Deed
H.O.A. Approval
IN HOUSE: -
Planning Approval
Pub. Wks. Appr
School Fee,
,q'd
APPLICANT:
Rec'd
Estimated Value ofPrcject: X
DO NOT WRITE BELOW THIS LINE
TRACKING PERMIT FEES
Plan Check submitted Item Amount
Reviewed, ready for corrections Plan Check Deposit
Called Contact Person Plan Check Balance
Plans picked up . Construction
Plans resubmitted. Mechanical
tad Review, ready for corrections/issue Electrical
Called Contact Person Plumbing
Plans picked up S.M.I. '
Plans resubmitted Grading
''" Review, ready for corrections/issue Developer impact Fee
Called Contact Person A.1 P P
Date -of permit issue
Total Permit Fees