05-0601 (TT)-BUILDING & SAFETY DEPARTMENT
P.O. Box 1504 (760).777-7012
OF94`' 787495 CALLS TAMPICo ' FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTION REQUESTS (760) 777-7153
BUILDING PERMIT
Application Number . . 7,050.0.0.0.0.6.0-1Date 2/16/05
Property Address 80435 VIA SAVONA `
APN: 772-410-998-F -32453 -
Application description.. TEMPORARY 'TRAILER
Property Zoning `LOW DENSITY RESIDENTIAL
Application valuation . . . 300
Owner Contractor
ND LA QUINTA PARTNERS A & M CONSTRUCTION
375 N FRONT ST STE 200 P.O. BOX 366
,COLUMBUS OH 43215 LA QUINTA CA 92253
..(760) 564-4832
WCC: STATE FUND
WC:, 0009232-2005 01/01/06
CSLB: 746198 02/28/.06
CCC:_ B -C10
-Permi•t . . . . . . . TEMP -TRAILER,/ MOBILE HOME
Additional desc,
Permit Feb 200.00 Plan Check Fee .00
Issue Date Valuation 300
Qty Unit. Charge Per Extension
BASE FEE 200.0.0
Special Notes and Comments
TEMPORARY.TRAILER PER MUP 2005-608
Fee summary Charged Paid, -Credited Due
Permit Fee Total 200.00 .00 .00 200.00
Plan ck Total .00 00 :00 .00
Gran 200.00 .00 .00 200.00
P.O. BOX 1504 TAW "
f 4 4 VOICE (760) 777-7012
78-495 CALLE FAX (760) 777-7011
LA QUINTA, CALIFORNIAFOR 92253 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number: J� 601 Date:
Applicant: I Architect or Engineer:
Applicant's Mailing Address:
CON T/oA c roj2
Architect or Engineer's Address:
Lic. No.:
t$UILUINU. PERMIT DECLARATIONS
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
C e, and my License is i ful for nd t. '
icense Class 24%1 License (p(
,We !i dcontractor
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 for a permit subjects
the applicant to a civil penalty of not more than five hundred dollars ($500).):
U 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 this reason
Date
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
y[ 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
ued(My wgr)cers' cosation insurance Carrieyend policy number are:
Carrier Gi `h Cts} -2 /e�t1 �J 1/ Policy Number/ (� 0,9 .7 Z 3 Z - Z b�
— I certify that, in thd 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 Califomia, d 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 pro v' ions.
C. ate _ el -11, ~
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
r.�
Lender's Address
APPLICANT ACKNOWLEDGEMENT `.,r<%��
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set to on' -this application.
1. Each person upon whose behalf this application is made, each person at whose request and for whose benefit work is' *4 o"ed 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 hoI' harmless the City of La Quirita, its
officers, agents and employees for any act or omission related to the work being performed under or following issuance of itis permit.
2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from datepf issuance°of such,permit, or
cessation of work for 180 days will subject permit to cancellati n. �y W.=
I certify that I have read this application and state that the above inform ion 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 r upon the above-mentioned property for inspection purposes. �!
/teSignature (Applicant or Agentf /