BP 11-0437P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Tjht 4 4 Q"
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 5/ 02 / 11
Application Number: 11-00000437
Owner:
Property Address: 52060 AVENIDA ALVARADO
CARLO RODRIGUEZ
APN: 773-214-003-20-000000-
52060 AVENIDA ALVARADO
Application description: PLUMBING
LA QUINTA, CA 92253
Property Zoning: COVE RESIDENTIAL
Application valuation: 2500
s' -
Contractor: rf
Applicant: Architect or Engineer:
SO CAL & ASSOCIATES PLMBNG INC
P.O. BOX 955
YUCCA VALLEY, CA 92286
(760)369-4104
Lic. No.: 793482
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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 Profession se is in full force and effect.
I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided
License Class: B C36 C License No.: 79348
_
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
�`/' issued.
-4 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
OWNER -BUILDER DECLARATION
insurance carrier and policy number are:
I hereby affirm under penalty of perjury that 1 am exempt from the Contractor's State License Law for the
Carrier EVEREST NATL Policy Number 760007142111
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
3700 of the Labor Code, I shall f
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).:
te: M" ,/ �. I" - — -
(_) 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: FA LIRE 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 sold within
SECTION 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.).
(_) 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.).
(_ 1 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:
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 pursuant to any permit issued as a result of this application,
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.
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.
I certify that I have read this application and state that the above information is correct. I agree to comply with all
city and ounty ordinances and state laws relating to building cons uthorize representatives
of th" county to enter upon the above -mentioned or ins ses.
ate: Si tur
LQPERMIT
Application Number . . . . . 11-00000437
Permit . .
. PLUMBING SEWER
Additional desc .
.
Permit Fee . . .
. 30.00
Plan Check Fee
.00
Issue Date . . .
.
Valuation . . .
. 2500
Expiration Date .
. 10/29/11
Qty Unit Charge Per
Extension
BASE FEE
30.00
----------------------------------------------------------------------------
Special Notes and
Comments
SEPTIC ABANDON, SEWER CONNECT. 2010
CODES.
----------------------------------------------------------------------------
Other Fees . . .
. . . . . . BLDG STDS ADMIN (SB1473)
1.00
Fee summary
-----------------
Charged Paid
--------------------
Credited
--------------------
Due
Permit Fee Total
30.00
.00 .00
30.00
Plan Check Total
.00
.00 .00
.00
Other Fee Total
1.00
.00 .00
1.00
Grand Total
31.00
.00 .00
31.00
LQPERMIT
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