05-3396 (BLCK)• i
P.Q. BOX 1504 .._ VOICE (760) 777-7012
;£ 78-495 CALLE TAMPICO D� FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 B ING & SAFETY D P TMENT; INSPECTIONS (760) 777=7153
B�1rGDJMqR .I
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statement or she rs ant th th
Date: 8/03/05
Application Number: 05-000.03396 CIT1'OF
FLNq�
Owner:
Property Address: .. 57389 VIA VISTA EDEP�7
PUERTA AZUL PARTNERS
-APN: 762-240-003-29 -3009627
17700 SW UPPER BOONES'FERRY RD.
Application description: WALL/FENCE
SUITE 100
Property Zoning: MEDIUM DENSITY RES
PORTLAND; OR 97224
Application,valuation: 1848 ,
^
Contractor:
Applicant: Architect or Engineer:
DAVIS/REED CONSTRUCTION INC
WCC: STATE FUND '
WC: WC298892005 06/30/06
- CSLB: 8.13480 10/31/06
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.. LIC ED N CTOR'S D TION —.-
- WORKER'S COMPENSATION DECLARATION -
' I hereby irm u er p ty of perjury I am I' nse under provi ' n Chapter 9 Ic
I hereby affirm under penalty of perjury one of the following declarations:
- Secti 000) Di-' ion 3 of the ness and, rofe onals Code m : s ull force and effect. •.
_ I have and will maintain a certificate of consent -to self -insure for workers' compensation, as provided
a las Li
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
/
' at • C61 .actor/ : -
issued. `
I have and will maintain workers' compensation insuranc wired by Section 3700 of the Labor • .
- -
' Code, for the performance of the wo is is permit is issued�My�w\orkers' compensation • -
OWNER -BUIL ECLARATION - -
'
-insurance carrier and policy er are:
I her by um under penalty of perjury at I am exempt from the Contractor's State License Law for the " -
Carrier
B . Policy Number - - - - - - - - -
foil in eason (Sec. 7031 .5, Business and Professions Code: Any city or county that requires a permit to -
-
I ify th m the ormance of the work for tis permit jissue , I shall not mploy any
- co stru , atter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the *
- ermit to file a si ned that he is licensed t f C S
per n any an tieco su the worker co nsation laws of alifornia,
---' -•- - ' -'--• •'-' '------- • • •`- •-•-•'--•-' - ----^--- --•-••'-°----- _ �---••----
p g pu u o e provisions o e ontractor s tate ..
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 apermit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
(_ I I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and
the structure isnot 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.).
(._ 1 1, 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.). -
(_ I I am exempt under Sec. , B.&P.C. for this reason
'Date: Owner: - -
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:
Lender's Address: - -
LQPERMIT
f00' of the Labor Co e, s In r[h ply with a provisions.
Applicant:
ZqO
ARNI FAILURE TO SE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL. -
SUBJ T AN EMPLOYER T CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOL RS ($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.
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 purs••ter ' ' as a result'of this application,
the owner, and the applicant, eac o, and shall defend, indemnify an Id.harmless the City
of La'ouinta, its officers,
sand employees for any actor omission related to the work being
performed under or fo wing is
of this permit.
2. Any permit issued as .result of this application becomes null and void if k is not c enced
within 1/nn.
m e of issuance of such permit, or cessatio r _ ys will subject
per o -
certify I av a e that the above info t tree ply with I
citya o y o dinate laws relating to building co ere aut h ativ
of " e e above-mentioned property fo 0 0
Da Signature (Applicant or Agent).
t
.': .., Application Number 05-00003396
Permit . . . . . WALL/FENCE PERMIT
Additional desc .
Permit Fee .: 43.00
Plan Check Fee°
.00
Issue Date
Valuation ..
1848
Expiration Date 1%30/06.
Qty Unit Charge Per _...
Extension
BASE - FEE
15.00
14.00 2'.0000 HND BLDG 501-2,000
28.00
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Special Notes and Comments
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56 L.F. 6- GARDEN WALL,.28 L.F. 4 -
GARDEN WALL & 6.L.F.'2' GARDEN, WALL;,
ORCO SYSTEM.
Fee summary Charged Paid
Credited -
- - - - ---
Due
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„.
Permit Fee.Total 43_00
.00: .00
43.00.
i:. Plan Check Total .00'
00 00'
00
Grand. Total 43.00 -.00
.0.0
43.00:
LQPERNIIT
-