05-5479 (BLCK)�.07.%OX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
Property Address:
APN:
Application description
Property Zoning:
Application valuation:
Applicant:
05-000_0.5479
81825 GOLDEN STAR WY
764-280-999-82 -300235-
WALL/FENCE
MEDIUM HIGH DENSITY RES
1375
T4'yl °F4w
Architect or Engineer:
Z) 1pk
& SAFETY DEPARTMENT
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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 Divi ion 3 of the Business�Professionpls ode, and my License is in full force and effect.
Licenfi`U B Lic se No.: 672285
ate: •u ntractor:
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 (5500).:
(_ 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 (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 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: PC
LQPERMIT
PERMIT
Owner:
SHEA LA QUINTA
C/O JEFF MCQUEEN
8800 N GAINEY CENTER 350
SCOTTSDALE, AZ 85258
Contractor:
SHEA HOMES, INC.
81260 AVENUE 62
LA QUINTA, CA 92253
(760)777-6005 .
LiC. No.: 672285
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
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WORKER'S COMPENSATION DECLARATION
Date: 12/16/05
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 AMERICAN HOME A Policy ber 1247619
_ I certify that, in the perfo of thew or which this permit is issued, I shall not employ any
person in any manner s as becom jest to the workers' compensation laws of California,
and agree that, if I shou d be o lect to the workers' compensation provisions of Section
3700 of the Labor C h II fort comp a provisions.
A ant:
WARNING: FAILURE TO SECURE WORKERS' 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 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 t ' application becomes null and void if work is not commenced
within 180 days from date of is nce of such permit, or cessation of work for 180 days will subject
permit to cancellation.
I certify,that I have rea this application and to tat the abov formation is correct. •1 agree to comply with all
city an o ni ordina ces and state law o buildi struction; and hereby authorize representatives
oft ' ty n r on the above -m roperty fo nspection purposes.
Date: nature (Applic or Agent):
LQPERMIT
Application Number . . . . . 05-00005479
Permit . . . WALL/FENCE PERMIT
Additional desc . .
Permit Fee . . . . 33.00 Plan Check'Fee 00
Issue Date . . . . Valuation . . . . 1375
Expiration Date . . 6/14/06
Qty Unit Charge Per
BASE FEE
9.00 2.0000 HND BLDG 501-2,000
Fee summary Charged Paid
Permit Fee Total 33.00 .00
Plan Check Total .00 .00
Grand Total 33.00 .00
Extension
15.00
18.00
Credited Due
.00 33.00
.00 .00
.00 33.00