05-5139 (SPIN)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: 05-000051.39
Property Address:
50620 EISENHOWER DR
APN:
773-370-029= -
Application description:
SPECIAL INSPECTION
Property Zoning:
MEDIUM DENSITY RES
Application, valuation:
21500
TiAt 4 XA Q"
.Applicant: Architect or Engineer:
ell', �)[Jlk
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
------------------- ------------------------- I --------
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 Bualness,and Professionals Code; and my License is in fill force and effect.
License Class: A B Ucense_No::. 266187
Date: Contractor:
OWNER -BUILDER DECLARATION.
1 hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Lawlor 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;applicarrf for the
permit to file a signed statement thst 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 Businewand Professions Code) or
that he or she is exempt therefrom and the tussis for the alleged exemption. Any violation of Section 7031:6: by
any applicant for a permit subjects the applicant•to a civil penalty of not.more than five hundred dollars (8500).:
1 _ 1 I,,as owner of the property,.- 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.forthe purpose of sale.).
() I, as owner of the property,.em exclusively contracting with licensed contractors to construct the project (sec.
7044, of
and Professions Code: The Contractors' State License Law does not apply to an owner of
property who builds or improves thereon, an ho contracts for the projects with,a contractors) licensed
pursuant.to the Contractors' State License ).
(_) I am exempt under Sec. _ , Bf &P.C: f his reason Al
a nor: ���'��•(�l lam—
CONSTRUCTION LENDING'AGENCY
I hereby affirm under. penalty of perjury that there is a construction -landing agency for the performance of:the
work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name:
Lender's Address:
r • "I'
Owner:
APTS@LQ VILLAGE LP
1105 QAUIL ST
NEWPORT BEACH, CA 9266
Contractor:
MARK COMPANY
2288 BATAVIA
ORANGE, CA 92865
(714,)685-2462
Lic.. No.: 266187
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 11/23/05
D Q
NOV ' 2 3 2005
CITU OF 4.A QUINT'A
FINANCE DEPT.
------------------
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.
1 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 polity number are:
Carrier STATE FUND Poli Number 046-0010738
I oertify'that, in the performance of th rk for which this permit is issued, I shall not employ any
person In any manner so as fo a subject to the workers' compensation lawsW California,
and agree that, if I should becom bject to thew compensation.provisions of Section
37PO of,the Labor C- , I shal - with comely ovisions.
y71B: V / cent`
/WARNING: FAILURE TO SECU ORKERS' COMPENSATION COVERAGE:IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (8100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 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
condltions,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 becom II and void lf'work Is not commenced
within 180 days from date of issuance of such perm , or cessation of work for 180 days will subject
permit to cancellation.
I certify that 1 have read this,-application,ard state that the abov- n -ation is I agree to comply with all
city and county ordinances and state laws relating to'building ction, a horize representatives
of this ceu to enter upon the above-mentioned pro for ' ion
In A ' ture.(Applicant or Agent):
Application Number . . . . . 05-00005139
Permit. . . . SPECIAL INSPECTION
Additional desc .
Permit Fee . . . 100.00 Plan Check
Fee
.00
1.
Issue Date . . . Valuation
. . .
. 21500
Expiration Date . 5/22/06
Qty Unit Charge Per
Extension
BASE FEE
100.00
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Special Notes and. Comments
SPECIAL INSPECTION OF SHELL IN ORDER TO
POUR NON-STRUCTURAL SLAB IN PREPARATION
FOR TI & EXTENSION OF UNDERGROUND
PLUMBING ABOVE FINISH GRADE
Fee summary Charged Paid Credited
Due
Permit Fee Total 100.00 .00
.00
100.0.0
Plan Check Total .00 .00
.00
.00
Grand Total 100.00 .00
.00
100.00
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