05-3092 (BLCK)P.O. BOX 1504 .
78-495 CALLE TAMPICO ,
LA QUINTA, CALIFORNIA 92253
Application Number:
Property:Address:
APN:
Application description:
Property Zoning:
Application valuation:
Applicant:
05-00003092
79790 VIA SIN CUIDADO CT .
772-390-005- - -
WALL/FENCE
LOW DENSITY RESIDENTIAL
1525
Architect or Engineer:
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
I
JUL 2 5 0
Owner:
R J T HOMES
1425 E UNIVERSITY DR
r_PYOENIX, AZ 85034
RJT HOMES LLC
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760)'777-7153
Date: 7/21/05
UNIVERSITY DRIVE
-�lldAld ~
P
PHOENIX, AZ 85034
pip
(760) 123-4567 ,
LiC. No.: 690645
n
LICENSED CONTRACTOR'S DECLARATION
WORKER'S COMPENSATION DECLARATION
I 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.
Ihave and will maintain a certificate of consent to self -insure for workers' compensation, as provided
License Class: A -.B ._ License No.: 690645
_
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
1
ontractor. 11�--
issued.
K I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor.
T- 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 STATE FUND Policy Number 1583 906
following reason (Sec. 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
- that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
3700 of the Labor Code, I shall forthwith comply with [hose rovisions.
.
_pplicant:
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
Date:1__7K IS
. (_) '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
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL
_ Contractors' State License Law does not apply to an owner of property, who builds or, improves thereon,
SUBJECT AN EMPLOYER TO CRIMINAL 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
DOLLARS ($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 soldwithinSECTION
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 1, 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,
(_) I 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 employees for any act or omission related to the work being
performed under or, following issuance of this permit.
• Date: Owner:
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
CONSTRUCTION LENDING AGENCY -
permit to cancellation.
hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the
I certify that I have read this application and state that the above information is correct. I agree to comply with all
work for which this permit is issued (Sec. 3097, Civ. C.). - -
city and county ordinances and state laws relating to buildin construction, and hereby authorize representatives
- -
Lender's Name:.
.of this county to enter upon he above-mentioned pope r i pection purposes. -
.. -
C
e: �J ' , ignature (Applicant or Agent):
Lender's Address:
IV
" LQPERMrT - .•
..
Application Number . . . 05-00003092
' Permit . . . WALL/FENCE PERMIT
Additional desc .
Permit Fee. 37.00 Plan Check
Fee
00
Issue -Date Valuation
1525
- - Expiration Date 1/17/06
Qty. Unit Charge Per/
Extension
BASE FEE
15.00..
•11.00 2.000.0 HND BLDG 501-2,000
22.00-
- .. Special Notes and Comments
61 L.F. 6' GARDEN WALL, ORCO SYSTEM
Fee summary Charged Paid. Credited
Due
Permit Fee Total 37.00 .00
.00
37'.00
" Plan Check Total .00 .00
.00.
.00.
Grand Total 37.00 .00
.00
37.00
LQPERMIT • -