05-2089 (PLBG)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: OS -0000.2089
Property Address:
APN: 78190 CALLE FORTUNA
Application description:, 770-154-004-4 -0000,00
Property Zoning: PLUMBING L
Application valuation: LOW DENSIT
Applicant:
MAY 31 1005
CITY Of
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 Professionals Code, and my License is in full force and effect.
License Class: �7�933482 License No.: EXEMPT
Date: ,Iracter+l�
OWNER -BUILDER DECLARATION
I 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.).
(_ 1 1, 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.).
I—) 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
FETY DEPARTMENT
NG PERMIT
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 5/31/05
Owner:
---------------------------------
DUNLAP DEAN A
78190 CALLE FORTUNA
LA QUINTA, CA 92253
Contractor:
SO CAL PLUMBING & REPIPE CO
P.O. BOX 955
YUCCA VALLEY, CA 92286
Lic. No.: EXEMPT
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 performance of the work for which this permit is issued. My workers' compensation
insurance carrier and policy number are:
Carrier 4104 Policy Number' EXEMPT
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 forthwit� 'y •-•
WARNING: FAILURE TO SECURMMORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($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.
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 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 above information is correct. I agree to comply with all
city and county ordinances and state laws relating to buildin hereby authorize representatives
of this county to enter upon the above -me party for inspection purposes.
'7
Application Number . . 05-00002089
Permit . . . . . . PLUMBING SEWER
Gi Additional desc . .
Permit Fee . . . . 30.00
Plan Check
Fee
.00
Issue Date . . . .
Valuation
. . .
. 2500
Expiration Date 11/27/05
Qty Unit Charge Per
Extension
BASE FEE
30.00
---------------------------------------------------------
------------------
Special Notes and Comments
SEWER CONNECT/SEPTIC ABANDONEMENT
Fee summary Charged Paid
Credited
Due
Permit Fee Total 30.00
00
.00
30.00
Plan Check Total .00
.00
.00
- .00
Grand Total 30.00
.00
.00
30.00
C,
LQPERMIT
d
y1
AwSmAmPa
PUMP/NG
Lic #C42 855 851
low .7LO- / oo / 0"
CUSTOMER'S ORDER NO.
DAT ORDERED
FAX 760 328-6607
/V1C�
P.O. Box 2318 • Cathedral City, CA 92235
ORDER TAKEN BY
DATE PROMISED ❑ A.M.
dq
Pumping Fee per 1000 gal. PUWD
❑ P.M.
BILL TO O
PHONE
1
ADDRESS n /]
• j "17
'
MEC ANIC
CITY
HELPER
JOB NAME AND LOCATION
❑ DAY WORK
DESCRIPTION OF WORK
❑ CONTRACT
❑ EXTRA
r
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
Gallons
Pumping Fee per 1000 gal. PUWD
Dumping Fee per 1000 gal.
Out of Area Fee
Locating / Opening Fee (per hour)
Size Syste
`
i
A SERVICE CHARGE OF $20 WILL BE DUE ON ALL RETURNED CHECKS.
18% PER YEAR WILL BE CHARGED ON PAST DUE
ACCOUNTS OVER 30 DAYS.
TOTAL
MATERIALS
TOTAL
LABOR
WAIVER: Not responsible for secondary damage suc s�vate
damage, chipped concrete, mar n.streellor wewa s or trees.
SIGNATURE DATE COMPLETED
TAX
TOTAL
VALLEY WATER DISTRICT CASH RECEIPT DETAIL N 0
I, _ _
Received From:
Address:
Account No " I v • -% Lot(s) A
Service Address --IV — I a 0
❑ Meter(s)
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ Detector Check(s)
❑ Meter Surcharge
A Sanitation Capacity Charge S�
❑ W.S.B.FC.
❑ S.I.W.S.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water / Sewer -
Tract -
❑ Bond Payment -A.D. - Bond Assmt
❑ Customer Deposit
❑ Other
Remarks:
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