05-1998 (RPL)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253,
Application Number:
Property Address:
APN:
Application description
Property Zoning:
Application valuation:
Applicant:
05-00001998
53072 VIA DONA _
772-410-999-14 -298944-
POOL - RESIDENTIAL
LOW DENSITY RESIDENTIAL
30000
Architect or Engineer
,t4
BUILDING.& SAFETY DEPARTMENT
BUILDING PERMIT
Owner:
-ROSS
53-072 VIA DONA
LA QUINTA, CA 92253
ontractor:
k INSWORTH POOL CONSTR, ROBERT
VOICE (760) 777-7012.)
FAX (760) 777-7011.
INSPECTIONS (760) 777-7153
Date: 5/24/05
Q ooAe CC: VIRGINIA SURETY
J WC: 005-0024833 01/01/06 C
' LICENSED CONTRACTOR'S DECLARATION "
I hereby affirm under penalty of.perjury that I am licensed under provisions of Chapter 9 (commencing with
action 7000) of,ffi a ' n 3 of the Business and Professionals Code, and �TY/ 9s i i full force and effect.
Licensel ss: "• LLy�.• n License Nor'
Contractoy
.. - 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 acivil penalty of not more than five hundred dollars ($500).: ,
1 _ 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.).
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 am exempt under Sec. , B.&P.C. for this reason
Date: Owner:
CONSTRUCTIONLENDING 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 ISec. 3097, Civ. C.).
Lender's Name:
Lender's Address:
LQPERmrr
CSLB:' 598681 07/31/06
,
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations: -
have and will maintain a certificate of consent to self -insure for workers' compensation, as provided
for by Section 3700 d 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: �r rl,1
at
/ar C53 Policy Number,/F/(/-� "- i* I -W_%
I certify that, in the performance of the work for which this permit is issued, 1 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,.] shall forthwith
forthwith comp,with those provisions.
D /�� APPlicaAt✓ ! � I. A6Lt1 I�
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. '
r 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 stateAhe information is correct. I agree to comply with all
city and county ordinances andstate laws relatingnstruction, and hereby authorize representatives
of thi my enter upon the above-mentionedspection purposes.
Date: vS Signature (Applicant or Agen
LQPERMTT .
Application Number .
. . . 05-00001998
Permit . . .
BLDG POOL•PERMIT
Additional desc .
Permit Fee.
284.50..- Plan Check
Fee
184.93
Issue Date
Valuation
30000
Expiration Date .
11/20/05
Qty Unit Charge
Per
Extension
BASE FEE.
252.00 -
5.00 6.5000
THOU BLDG 25,001-50,000
32.50
Permit . . .
MECH POOL
Additional desc .
J
Permit Fee
26.00 Plan Check
Fee
6.50
Issue Date
Valuation
0
Expiration Date
11/20/05
Qty Unit Charge
Per
Extension
BASE FEE
15.00•
- .1.00 11.0000
EA_' MECH FURNACE >100K
Permit, . .
ELEC POOL PERMIT -RES
Additional desc
Permit Fee . .
45.00 Plan Check
-Fee
11.25
Issue Date.
Valuation
. . .
0
Expiration Date ..
11/20/05
Qty Unit Charge
Per
Extension
BASE FEE
15.00
1.00 30.0000
EA ELEC PRIVATE SWIMMING POOL
---------------------
30.00
Permit . . .
PLUMBING
Additional desc
r Permit, Fee
33.00 Plan Check
Fee
8.25
Issue Date
Valuation
0
Expiration Date:.,.
11/20/05
Qty Unit. Charge
Per
_
Extension
BASE FEE
15.0 ,0
2.00 6.0000
EA PLB FIXTURE
12.00
1.100 :3.0000
EA .PLB WATER INST/ALT/REP
3.00
1..00 3.0000'EA
PLB GAS PIPE 1-4 OUTLETS
3.00
•Special Notes and Comments
POOL & SPA ONLY.'ALARMS/BARRIERS SHALL
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