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BWFE2015-0030V LICENSED CONTRACTOR'S DECLARATION WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter I hereby affirm under penalty of perjury one of the following declarations: 9 {commencing with Section 70001 of Division 3 of the Business and Professions Code, �iLfI{�lCl/ and my License is in full force and effect. VOICE (760) 777-7125 78'495 CALLE TAMPICO D FAX (760) 777-7011 LA QUINTA, CALIFORNIA 92253 COMMUNITY DEVELOPMENT DEPARTMENT INSPECTIONS (760) 777-7153 BUILDING PERMIT OWNER -BUILDER DECLARATION Carrier: _ Policy Number: I hereby affirm under penalty of perjury that I am exempt from the Contractor's State I certify that in the performance of the work for which this permit is issued, I License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any Date: 1/23/2015 Application.Number BWFE2015-0030 compensation laws of California, and agree that, if.1 should become subject to the Owner: workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith Property Address:. 80871 VISTA LAZO comply with those provisions. SMITH RESIDENCE APN: 762250010 Date:/ -2-1- Z 2 07 Applicant: / 80871 VISTA LAZO Application Description: 140 LN FT X 6 FT HT BLOCK WALL LA QUINTA, CA 92253 ($500).: Property Zoning: (_) 1, as owner of the property, or my employees with wages as their sole' ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF compensation, will do the work, and the structure is not intended or offered for sale. Application Valuation: $5,000.00 (Sec. 7044, Business and Professions Code: The Contractors' State License Law does not INTEREST, AND ATTORNEY'S FEES. D himself or herself through his or her own employees, provided that the improvements APPLICANT ACKNOWLEDGEMENT Applicant: IMPORTANT: Application is hereby made to the Building Official for a permit subject to Contractor: the conditions and restrictions set forth on this application. DOBBINS MASONRY, LENNYDOBBINS ; JAN 2 3 201 � MASONRY, NNY request and for whose benefit work is performed under or pursuant to any permit 0 OUTSIDE CITY LIMITS issued as a result of this application , the owner, and the applicant, each agrees to, and 0 OUTSIDE CITY LIMITS shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and LA QUINTA, CA 92253 CITY OF LA QUINTA LA QUINTA, CA 92253 following issuance of this permit. COMMUNITY DEVELOPMENTDEPARTMENT (760)568-5880 not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. Llc. No.: :LIC -0000293 ' LICENSED CONTRACTOR'S DECLARATION WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter I hereby affirm under penalty of perjury one of the following declarations: 9 {commencing with Section 70001 of Division 3 of the Business and Professions Code, I have and will maintain a certificate of consent to self -insure for workers' and my License is in full force and effect. compensation, as provided for by Section 3700 of the Labor Code, for the performance License Class: License No.: :LIC -0000293 of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required Date: (��a / � Contractor: 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: OWNER -BUILDER DECLARATION Carrier: _ Policy Number: I hereby affirm under penalty of perjury that I am exempt from the Contractor's State I certify that in the performance of the work for which this permit is issued, I License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any shall not employ any person in any manner so as to become subject to the workers' city or county that requires a permit to construct, alter, improve, demolish, or repair compensation laws of California, and agree that, if.1 should become subject to the any structure, prior to its issuance, also requires the applicant for the permit to file a workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith signed statement that he or she is licensed pursuant to the provisions of the. comply with those provisions. Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Divisio of the Business and Professions Code) or that he or she is exempt therefrom and the Date:/ -2-1- Z 2 07 Applicant: / basis for the alleged exemption. Any violation of Section 7031.5 by any applicant fo a permit subjects the applicant to a civil penalty of not more than five hundred dollars WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 15 UNLAWFUL, ($500).: AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO (_) 1, as owner of the property, or my employees with wages as their sole' ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF compensation, will do the work, and the structure is not intended or offered for sale. COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, . (Sec. 7044, Business and Professions Code: The Contractors' State License Law does not INTEREST, AND ATTORNEY'S FEES. 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 APPLICANT ACKNOWLEDGEMENT are not intended or offered for sale. If, however, the building or improvement is sold IMPORTANT: Application is hereby made to the Building Official for a permit subject to within one year of completion, the owner -builder will have the burden of proving that, the conditions and restrictions set forth on this application. he or she did not build or improve for the purpose of sale.). 1: Each person upon whose behalf this application is made, each person at whose (_) I, as owner of the property, am exclusively contracting with.licensed contractors request and for whose benefit work is performed under or pursuant to any permit to construct the project. (Sec. 7044, Business and Professions Code: The Contractors' issued as a result of this application , the owner, and the applicant, each agrees to, and State License Law does not apply to an owner of property who builds or improves shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and thereon, and who contracts for the projects with a contractor(s) licensed pursuant to employees for any act or omission related to the work being performed under or the Contractors' State License Law.), following issuance of this permit. (� I am exempt under Sec. B.&P.C. for this reason 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. Date: Owner. I certify that I have read this application and state that the above information is correct., CONSTRUCTION LENDING AGENCY I agree to comply with all city and county ordinances and state laws relating to building I hereby affirm under penalty of perjury that there is a construction lending agency for construction, and hereby authorize representatives of this city to enter upon the above• the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). mentioned property for inspection purposes. Lender's Name: - date: ' 2 " >'� Signature (Applicant or Agent): Lender's Address: J XVQ W3 MH Mvo lum -61p noA —to&eq III&C) zo VLLNifl?j lvq lao JIM 31vu 0 -Aftalq3q -.4-4— —.34 Z=19d 'ON Ma MM 'WH *IM*L "M KOUM A0 K-�- 04-69/99Z 93q t'COOZ 10VUl ON103NIOd WE - —im —01W ol lori HJIVD S'Norl I(ZZ3 M90 �N • AVG 103HO tr� emwm — — NVId ONI(lVao- SSIOaad GO tm -- aim ;Noma ZoNaalsau Hliyqs -JO H05VA0,1M ZU tOW CMAGM tOz/-'/- OZVrl VISIA XXX—XX oTo—o9z—E94 :Ndv0stees+ --AV AM - W, Tn M dl PUMP cc 02 ol G 0 I .01=,1 3TIM res j --- - - - - - CITY OF LA QUINTA BUILDING & SAFETY DEPT. APPROVED. vf, z FOR CONSTRUCTION F N C T FB U I NOG & QETUY I DEF pp @9 l= Ri n 4-- INYOVA - 1 & ow hyw Wu HD KWM LM ad am w SM.9 a= 3WW MN 1W WS @ Ta R M KMMU 2' @ V a1 I LUG ND TaM Md•wfm Ixgum 'MW HVI LUG NO WM Md MM -N) Wsm .0 1wim 11 mm w 3m mm Nm Vw .w .t %I sm -am MM Tmm @ -MM W M16NV.0 '910 SM WdO M 0,09v da z -i im mD yam Md TaWW dM.01 LIMISM 9'69173=�ad I LIM MD 74M Wd MM MW I= Hu = asm TKW zl iwwm Q OT loql//4;t�, 101 .0=— I(W-HM-30 M." WM M"m I'M ""M tow o"m Q*W Wit XVWd3S Md TM OWSIM N ri4r, Will MD Now KM f. 9, -a.9 wi smi Nm (D law GWA ff saLLo.N,*ou—onHJ5N00 9., YE _HH -7 aovuvo -7)- 4r + is lot — — — — — — — — — — — — — -- Ht ..... —!smml— ur iI / xwq N 0 St Tim ZJ 1 10 ... ....... i . I aoNs(iisall *lsixa L, r -3f (Lv-oqt)=Lqd * -- I I trip Ism '10 Lmum A (Z-09v)=3d C[aAOHdd 6 IOTVA: — 141; FINANCIAL INFORMATION je3A k= a z•,a .y AIVIOUNT�r " DESCRIPTION #v .a?* ,ACCOUNT "'�"t,'y,3 �. PAID' PAIDDATE ,QTY ,. BSAS SB1473 FEE 101-0000-20306 0 $1.00 $0.00 PAID BY '����wr Total Paid forBUILDING STANDARDS ADMINISTRATION BSA $1.00 $0.00 _ , +. DESCRIPTIONS �a x �`, }` l:y: ^ ",s x i-4 s a ? M' .A000UNTjc?+` r TY h:,. : , . � � ;zAMOUNT � .. PAID,:" PAID DATE" . ;+ WALL/FENCE - EA ADDITIONAL 50 LF .101-0000-42404 0. 0' $62.36 $0.00 PAID;BY �,}... AA 4 -DESCRIPTION '"YMETHOD w" ra��;RECEIP,Ti#�+ rr "CHECK,# .'.: CLTD BYn': rg €� � '' , �' t ° '' ,gAACCOUNT S ` ; QTY i Vii, AMOUNT` `,, PAID PAID GATE! ., r�,C.. ..e , .. t z , xs t�.. t v r, r r. WALL/FENCE - FIRST 100 LF 101-0000-42404 0 $47.86 $0.00 METHOD;. CHECI(,#'# ' CLTD,.BY' id; x r s,',RECEIPT# , {QESCRIPTIONRi;w�a�y < trr�ACCOUNT '`QTY� + AMOUNT;4"PAID `x�" = PAID'DATE1 WALL/FENCE - FIRST 100 LF PC 101-0000-42600 0 $60.91 $0.00 b,v k - �. ':K'G e•�. F tai •i: #t - - +++ .y�;i�a { w •METHOD "'+v" '.3r ) x ;T P RECEIPT# xK;ga x -CHECK-# p CLTDtBY" t : Total Paid for FENCE OR FREESTANDING WALL $171.13 $0.00 ' TOTALS: } Description: 140 LN FT X 6 FT HT BLOCK WALL Type: WALL/FENCE Subtype: Status: UNDER REVIEW Applied: 1/23/2015 PJU Approved: Parcel No: 762250030 Site Address: 80871 VISTA LAZO LA QUINTA,CA 92253 Subdivision: TR 28034 Block: Lot: 10 f Issued: , Lot Scl Ft: 0 Building Scl Ft: 0 Zoning: .. Finaled:. Valuation: $5,000.00 Occupancy Type: Construction Type: Expired: No. Buildings: 0 No. Stories: 0 No. Unites: 0 Details: 140 LN FTX 6 FT HT BLOCK WALL PER CITY STANDARD RECISION CONCRETE BLOCK SHALL BE COVERED WITH STUCCO, PAINT, OR ' TEXTURED COATING WHERE VISIBLE FROM OUTSIDE THE PROPERTY. 2013CBC } • ADDITIONAL CHRONOLOGY CONDITIONS CONTACTS s .. .n"i ,P -� f: Y'" -".., - -.+-r.'-1.. -v'.. ^ x ... ` NAM E: ... :" 2`�°� .. -a+. ..�.. = :"^e-e.-cpN,. nxi"'+v� .. r4• "K:u �.. ... S : n.M.wF '' Si F%' `'{n6'.+. n Y., M� :",4 n .ti.�-Fa.•s 'M ..f-':akfi. • w✓i$.. `.r«x.. ...; e - i�"u .+„a... l 'i i-' �.h y�:+r_ .Na :a�'!✓r i qtr.-'•.-Z'#:a 3. '."'C,'! ,,. 4'{.:,.y '-,-{' APPLICANT DOBBINS MASONRY, LENNY 0 OUTSIDE CITY LIMITS LA QUINTA_ CA 92253 CONTRACTOR DOBBINS MASONRY, LENNY 6 OUTSIDE CITY LIMITS LA QUINTA CA 92253 , OWNER SMITH RESIDENCE J 80871 VISTA LAZO LA QUINTA CA 92253 FINANCIAL INFORMATION » :A K 'CLTD. ONCCOUNT AMOUNT -::t PAID EC#METH CH AID BYE, ``''' k. ✓ .• .3 .; BSAS SB1473 FEE 101-0000-20306. 0 $1.00 $0.00 Total Paid forBUILDING STANDARDS ADMINISTRATION $1.00 $0.00 BSA: Printed: Friday, January 23, 2015 1:45:03 PM 1 of 2 , N . i PARENT PROJECTS REVIEWS YITATUS_ -JRE -RETURNED,.! REVIEWER-.` 'SENT,DATE`. :DUES DATE 4—f N I 0 ts V,41REVIE A BOND INFORMATION ATTACHMENTS Printed: Friday, January 23, 2015 1:45:03 PM 2 of 2 C.IYSTEMS 70 77 INSPECTIONS 771z -7 O.SEQID�� DESCRiPT16N 7 - NS -ECT R _7 P, CITY, rcOia_p1ff__ ED -"bAtE Z_* I I DATE, RECEIPT# ..jCHECK*7^,CL METHODI FINAL" WALL/FENCE - EA - FOOTINGS I AORI . - 101-0000-42404 0 $62.36 $0.00 ADDITIONAL 50 I.F.- WALL/FENCE 101-0000-42404 -0 $47.86 $0.00 100 LF WALL/FENCE -FIRST 101-0000-42600 - 0 $60.91 $0.00 100 LF PC Total Paid forFENCE OR FREESTANDING WALL $171.13 $0.00 TOTALS: $172.13 $0.00 PARENT PROJECTS REVIEWS YITATUS_ -JRE -RETURNED,.! REVIEWER-.` 'SENT,DATE`. :DUES DATE 4—f N I 0 ts V,41REVIE A BOND INFORMATION ATTACHMENTS Printed: Friday, January 23, 2015 1:45:03 PM 2 of 2 C.IYSTEMS INSPECTIONS O.SEQID�� rrZilis CT.ION-TYPE Z) 7 - NS -ECT R _7 P, SCHEDULED; *.-DATE rcOia_p1ff__ ED -"bAtE Z_* �)41 RESOLT RE ARKS it. V- r - BOND BEAM FINAL" - FOOTINGS I AORI . - PARENT PROJECTS REVIEWS YITATUS_ -JRE -RETURNED,.! REVIEWER-.` 'SENT,DATE`. :DUES DATE 4—f N I 0 ts V,41REVIE A BOND INFORMATION ATTACHMENTS Printed: Friday, January 23, 2015 1:45:03 PM 2 of 2 C.IYSTEMS ' Permit # ProjeciAddress:�-� �%��l . Ccty o f La Quin to . Building 81: Safety Division P.O. Box 1504, 78-495 Calle Tampico . La Quinta, CA 92253.- (760) 777-7012 " Building Permit Application and Tracking Sheet LA120 Owner's Name: A. P. Number: Address: Legal Description: City, ST, Zip: Contractor:VJv N�� �� ii1 :' %r;'':s>z •:.. Address: L101 S /� �� d J -4,J) Project.Description: City, ST, Zip:. �T Telephone: S yIV W I '� State Lie. 4: ' Arch., Engr., Designer: Address: City., ST, Zip: Tele hone: » ` Construction Type; Occupancy: State Lic. #:. circle one): Ne% _ Demo tyPc w Addn Alter.te Name of Contact Person: Sq. Ft.: V. Stories: if Units: Telephone # of Contact Person:Estimated Value of Projcet: ' APPLICANT: DO NOT WRITE BELOW THIS LINE # Submittal Rcq'd Rcc'd TRACHING PERMIT FEES. Plan Sets PIan Check submitted FFIan Amount Structural Calcs. Reviewed, ready for corrections heckDeposit Truss Cala. Called Contact Person Plan Check Balance • TitIC24 Calcs. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan 2'' Review, ready for corrcctionsiissue Electrical Subcontac(or List Called Contact Person" Plumbing Grant Decd Plans picked up S.M.I. II.O.A. Approval Plans resubmitted Grading IN I10USE:- "4 Rcpiew, ready for corrcctionstissuc Developer Impact Fee Planning Approval Called Contact -Person A.I.P.P. Pub. Wks. Appr Date of permIt issue School Fccs Total Permit Fccs 7k6