BWFE2018-0044LICENSED 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 Professions Code,
and my License is in full force and effect.
License Class: B C33 C53 C-9 C10 C20 C36 C21 License o.: 581636
Date: Co cto�
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's 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
Contractor's 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).:
(_) 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 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.).
(_) 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.).
(_) 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:
(760)567-2347
Uc. No.: 581636'
WORKER'S COMPENSAT ON 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 370C of the Labor Code, for the performance
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 issued. My workers' compensation insurano! carrier and policy number are:
Carrier: STATE COMPENSATION INSURANCE FUND Policy Number: 9087965
I certify that in the performance of -he 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 California, and agree thct, if I should become subject to the
workers' compensation provisions of Section 3700 of the Labor C9�e, I shall forthwith
comply with those provisions.
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 ($100,007). 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 Building Official 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 pursuant to any permit
issued as a result of this application , the owne-, 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.
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 cancel ation.
I certify that I have read this application and st:+te that the above information is correct.
I agree to comply with all city and county ordirances and state laws relating to building
construction, and hereby authorize representa-.ives of this city to enter upon the
above-mentioned'pr perty for inspection purposes.
Date: �S�afu' a (Applicant or Agent):c J��
Ct
4 4 Qum&
VOICE (760) 777-7125
78-495 CALtE TAMPICO
D
fAX (760) 777- 7011
LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT
INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: 3/19/2018
Permit Type/Subtype:
WALL/FENCE/CITY STANDARD/PRE-APPROV
Owner:
Application Number:
BWFE2018-0044 Q
GEE FAMILY TRUST
Property Address:
51525 AVENIDA RUB.10 D t�
53 E ROANOKE S-1 .
APN:
773045025
SEATLLE, WA 98132
Application Description:
GEE/ 175LF OF ENGINEERED BL K IVfQR 1 218
Property Zoning:
Application Valuation:
CITY OF LAQUINTA
DEPARTMENT
Applicant:
COMMUNITY DEVELOPMENT
Contractor:
SIPOVAC CONSTRUCTION INC
SIPOVAC CONSTRUCTION INC
72651 THEODORA LANE
72651 THEODORA, LANE
PALM DESERT, CA 92260
PALM DESERT, CA 92260
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 Professions Code,
and my License is in full force and effect.
License Class: B C33 C53 C-9 C10 C20 C36 C21 License o.: 581636
Date: Co cto�
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's 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
Contractor's 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).:
(_) 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 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.).
(_) 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.).
(_) 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:
(760)567-2347
Uc. No.: 581636'
WORKER'S COMPENSAT ON 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 370C of the Labor Code, for the performance
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 issued. My workers' compensation insurano! carrier and policy number are:
Carrier: STATE COMPENSATION INSURANCE FUND Policy Number: 9087965
I certify that in the performance of -he 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 California, and agree thct, if I should become subject to the
workers' compensation provisions of Section 3700 of the Labor C9�e, I shall forthwith
comply with those provisions.
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 ($100,007). 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 Building Official 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 pursuant to any permit
issued as a result of this application , the owne-, 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.
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 cancel ation.
I certify that I have read this application and st:+te that the above information is correct.
I agree to comply with all city and county ordirances and state laws relating to building
construction, and hereby authorize representa-.ives of this city to enter upon the
above-mentioned'pr perty for inspection purposes.
Date: �S�afu' a (Applicant or Agent):c J��
J
Date: 3/19/2018
Application Number: BWFE2018-0044
Owner:
Property Address: 51525 AVENIDA RUBIO
GEE FAMILY TRU`•T
APN: 773045025
53 E ROANOKE ST
Application Description: GEE / 175LF OF ENGINEERED BLOCK WALL
SEATLLE, WA 98102
Property Zoning:
Application Valuation:
Applicant:.
Contractor:
SIPOVAC CONSTRUCTION INC
SIPOVAC CONSTFUCTION INC
72651 THEODORA LANE
72651 THEODORA LANE
PALM DESERT, CA 92260
PALM DESERT, CA 92260
(760)567-2347
---=-----------------------------------------------------------------------------------------
LIc. No.: 581636
Detail: 146 LF OF RETAINING UTILIZING ORCO DETAIL AT SOUTH SIDE YARD AND WEST REAR YARD, WITH 65 LF OF GARDEN WALL AT WEST PROPERTY LINE
(ORCO AND CITY STANDARD DETAILS) PRECISION CONCRETE BLOCK SHALL BE COVERED WITH STUCCO, PAINT, OR TEXTURED COATING WHERE VISIBLE
FROM OUTSIDE THE PROPERTY. THE AREA BETWEEN THE BACK OF CURB AND ANY FENCING SHALL BE LANDSCAPED, HAJE A SUITABLE PERMANENT
IRRIGATION SYSTEM, AND BE CONTINUOUSLY MAINTAINED BY THE PROPERTY OWNER. 2016 CALIFORNIA BUILDING CODES.
1
J
FINANCIAL
INFORMATION
ACCOUNT QTY
AMOUNT
RETAINING/COMBINATION WALL EA 50LF
101-0000-42400 0
$46.80
DESCRIPTION
ACCOUNT QTY
AMOUNT
WALL/FENCE - FIRST 100 LF
101-0000-42404 0
$52.01
DESCRIPTION
ACCOUNT QTY
AMOUNT
WALL/FENCE - FIRST 100 LF PC
101-0000-42600 0
$65.02
Total Paid for BLOCK "NALL:
$163.83
DESCRIPTION
ACCOUNT
QTY.
AMOUNT
RECORDS MANAGEMENT FEE
101-0000-42416
0
$10.00
Total Paid for RECORDS MANAGEMENIT FEE:
$10.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
TECHNOLOGY ENHANCEMENT FEE
502-0000-43611
0.
$5.00
Total Paid for TECHNOLOGY ENHANCEMENIr FEE:
$5.00