05-4381 (BLCK)4 P.O. BOX 1504 VOICE (760) 777-7012
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: 9/29/05
Application Number: ''05' 00004381 Owner:
Property Address: 80770 VIA PUERTA AZUL �PUERTA AZUL PARTNERS
APN: 762-240-003-20 -300962- ® 17700 SW UPPER BOONES FERRY RD
Application description: WALL/FENCE A SUITE 100
Property Zoning: MEDIUM DENSITY RES PORTLAND_OR OR 97224
Application valuation: 950 „h
710 Contractor:
Applicant: Architect or Engineer:°�P� o� DAVIS/REED CONSTRUCTION INC
E Q(/ 169 SAXONY ROAD, SUITE 105
ENCINITAS, CA 92024
(760)634-2350
Lic. No.: 813480
C SED C RACTOR'S DECLARATION WORKER'S COMPENSATION DECLARATION
I h by a rm der penalty of perjur t at am li sed under provisions of Chapter 9 (commencing with I hereby affirm under penalty of perjury one of the following declarations:
Se on 70 0) o Division 3 of the B s ss n rofessionals 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
i a s: License No.: 813480 for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
issued.
ate i ntract r: I have and will maintain wor 'compensation insurance, as required Section 3700 of the Labor
Code, for the perform ce of a work for which this permit i ued. My workers' compensation
OWNER -BUILDER DECLARATION nsurance carr' r an policy nu ber are:
I here y affi m under penalty of perjur that I am exempt from the Contractor's State License Law for the Carrier STA FUND Policy Number 98892005
following reason (Sec. 70'41 5; Rusin ss and Professions Code: Any city or county that requires a permit to I ertify th , in the erf anc of the work hich 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 pers in any ann o a o beco ject 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 gree tha , if I I ec 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 0 of the bor all forthwith comply with those provisions.
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 ($500).: t i pplicant:
(_ 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 A NIN / FAILURE TO SECU WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
Contractors' State License Law does not apply to an owner of property who builds or improves thereon, SU ECT AN EMPLOYER TO C MINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
and who does the work himself or herself through his or her own employees, provided that the DO RS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
improvements are not intended or offered for sale. If, however, the building or improvement is sold within SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
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.). APPLICANT ACKNOWLEDGEMENT
1 _ 1 I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the
7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of conditions and restrictions set forth on this application.
property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed 1. Each person upon whose behalf this application is made, each person at whose request and for
pursuant to the Contractors' State License Law.). whose benefit work is performed under or pursuant to any permit issued as a result of this application,
(_ 1 1 am exempt under Sec. , B.&P.C. for this reason the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City
of La Quinta, its officers, agents and p o any act or omission related to es for athe work b jng��
performed under or following issu a of this ermit.
Date: Owner: 2. Any permit issued a result of is applicatio becomes null and void i is not commenced
'thin
180 da rom date of ' suance of su permit, or ce of work for 180 days will subject
CONSTRUCTION LENDING AGENCY ermit to c ellation.
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the I certify h t haver this application a stat hat t a information is correct. I agree to comply with all
work for -which this permit is issued (Sec. 3097, Civ. C.). city and ty or ances and state law relati ing construction, and hereby authorize representatives
of thi c nt to enter upo a above -me o rty for inspection purposes.
Lender's Name:
ate: ignature (Applicant or
Lender's Address:
LQPERMIT
Application Number . . . . . 05-00004381
Permit . . . WALL/FENCE PERMIT
Additional desc . .
Permit Fee . . . . 25.00
Plan Check Fee
.00
Issue Date . . . .
Valuation . . .
. 950
Expiration_ Date . . . 3/28/06
Qty Unit Charge Per
Extension
BASE FEE
15.00
5.00 2.0000 HIND BLDG 501-2,000
10.00
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Special Notes and Comments
38 L.F. 6' BLOCK WALL, ORCO SYSTEM .
Fee summary- Charged Paid
-----------------
Credited
Due
------------------=-
Permit Fee Total 25.00
--------------------
.00 ..00
25.00
Plan Check Total .00
.00 .00
.00
Grand Total . 25.00
.00 .00
25.00
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