05-2134 (BLCK)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: 05-00002134
Property Address:
APN: 81255 LEGENDS WY
Application description: 762 -420 -028 -
Property Zoning: WALL/FENCE
Application valuation: LOW DENSIT
Appljcant:
T4 -h
t44Q"
BUILDING & SAFETY DEPARTMENT
Architect or Engineer:
a/k
IT
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Owner:
---------------------------------
TOLL CA V
KEVIN D DUERMIT
8901 E MOUNTAIN VIEW 200
Contractor:
TOLL BROS, INC.
73121 FRED WARING DRIVE, #100
PALM DESERT, CA 92260
Lic. No.: WA762DO04723014
Date: 6/02/05
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LICENSED CONTRACTOR'S DECLARATION
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WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with
I hereby affirm under penalty of perjury one of the following declarations:
Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect.
_ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided
License Class: 777699 License No.: WA762DO04723014
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
Date. `V/ tracto .
issued.
I have
ve 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
OWNER -BUILDER DECLARATION
insurance carrier and policy number are:
' I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the
Carrier 9699 Policy Number LIBERTY MUTUAL '
following reason ISec. 7031 .5, Business and Professions Code: Any city or county that requires a permit to
_ I certify that, in the performance of the work for which this permit is issued, I shall not employ any.
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the
person in any manner so as to become subject to the workers' compensation laws of California,
permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State
and agree that, if I should become subject to the workers' compensation provisions of Section
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
3700 of.Pe Labor Code, II forthwith comply with those provisions.
Late:?
that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
i 3
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
Applicant
(_) 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.).
(_) 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:
LQPERIIIIT
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 tha 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 building construction, and hereby authorize representatives
of this county to enter upon the above-mentioned property for inspection purposes.
r
Da et -�-13��i nature (Applicant or Agent): 42i���
LQPERAlff
Application Number . . . . . 05-00002134
Permit WALL/FENCE PERMIT
Additional desc .
Permit Fee . . . . 63.00
Plan Check Fee
.00
Issue Date . . . .
Valuation . . . .
3375
Expiration Date . . 11/29/05
Qty Unit Charge Per
Extension
BASE FEE
45.00
2.00 .9.0000 THOU BLDG 2,001-25,000
18.00
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Special Notes and Comments
135 L.F. 6' GARDEN WALL, ORCO SYSTEM
Fee summary Charged Paid
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Credited
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Due
`
Permit Fee Total 63.00
.00 .00
63.00
.Plan Check Total .00
.00 .00
.00
Grand Total 63.00
.00 .00
63.00