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05-1530 (BLCK)VV P.O. BOX 1504 cii� • '�C�� VOICE (760) 777-7012 78-495 CALLS TAMPICO FAX (760) 777-7011 La QuINrA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153 BUILDING & SAFETY DEPARTMENT Application Number: 05- I S oO . Date: US Applicant: I Architect or Engineer: Applicant's Mailing Address: c Architect or Engineer's Address: Lic. No.: BUILDING PERMIT DECLARATIONS 01A 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 License No. Date Contractor OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractors' 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 Contractors' 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 fora permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): 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 or 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.). U 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.). U I am exempt under Sec. , BA P.C. for thi reason �te 2Z G�j wrier WORKERS' 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 Policy Number 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 forthwith comply with those provision . 4� 2Z O S Date cant 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. 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 1 /� Lender's Address �✓ i'� 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 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 e e up the above-mentioned property for inspection purposes. ate 2Z G�j gnature (Applicant or Agent): ---------------------------------------------------------------------- Application Number . . . . . 05-00001530 Permit WALL/FENCE PERMIT Additional desc Permit Fee 63,00 Plan Check Fee .00 Issue Date Valuation,.. . . . 3200 Expiration Date 10/19/05 Qty: Unit Charge Per Extension BASE FEE 45.00 2.00 9.000O,THOU BLDG 2,001-25,000 18.00 Special Notes and Comments . 128 L.F. 6' GARDEN WALL,'CITY STANDARD Fee summary Charged Paid Credited 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 �,Bin # City of La Quinta Building 8t Safety Division P.O. Box 1504, 78-495 Calle Tampico La Quinta, CA 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet Permit # Project Address: --79 VIA MGL0Q1A A. P. Number: Owner's Name: /I Address: 70-73-SIIA 1-4 8 L 0 D/ A Legal Description: City,, ST, Zip: Contractor: `C L. JC' Telephone: -2 -7 1 —.23 7 ...... ... Address: . ......... ... Project Description: City,, ST, Zip: 6,- 4P_,0 6.Al Tel State Lic. # .... ..... . ...... .... .. ....IAI City Lic. #: Arch., Engr., Designer: Address: City-, ST, Zip: Telephone: K Construction TN pe: OccupancN•. State Lic. #: Project t) -pe (circle on Ne", Add.'n Alter Repair Demo Name of Contact Person: Sq. Ft.: # Stories: 4 Units: Telephone # of Contact Person: Estimated Value of Project: APPLICANT: DO NOT WRITE BELOW THIS LINE Submittal I Req'd Rec'd TRACKING PERMIT FEES Plan Sets Plan Check fo"bm;t!c� Item Amount Structural CaIcs. Reviewed, ready for corrections Plan Check Deposit Truss CaIcs. Called Contact Person Plan Check Balance Title 24 Caics. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan 2"' Review, ready for corrections/issue Electrical Subcontactor List Called Contact Person Plumbing Grant Deed Plans picked up S.M.I. II.O.A. Approval Plans resubmitted Grading IN IIOUSk:_ 'd Review, ready for corrections/issue Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub. Wks. Appr Date of permit issue School Fees Total Permit Fees