04-7659 (SIGN)P.O. Box 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number . .
Property Address . . .
APN:
Application description
Property Zoning . . . .
Application valuation .
Owner
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CASITAS LOS ROSAS
BUILDING PERMIT
BUILDING & SAFETY DEPARTMENT
(760).777-7012
FAX (760) 777-7011
INSPECTION REQUESTS (760) 777-7153
04-00007659 Date 12/09/04
50777 SANTA ROSA PLAZA
770-020-031-6-000000-
SIGN
. . . GOLF COURSE
2500
Contractor
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OWNER
PO BOX 1503
LA QUINTA CA 92253
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Permit . . . . . . SIGN PERMIT 1�lE
Additional desc
Permit Fee 54.00 Plan Check Fee .35
Issue Date . . . . Valuation 2500
Expiration Date . . 6/09/05
Qty Unit Charge Per Extension
BASE FEE 45.00
1.00 9.0000 THOU BLDG 2,001-25,000 9.00
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Special Notes and Comments
MONUMENT SIGN PER ORCO STANDARD & CDD
APPROVED PLANS
Fee summary Charged Paid Credited Due
Permit Fee Total 54.00 .00 .00 54.00
Plan Check Total .35 .00 .00 .35
Grand Total 54.35 .00 .00 54.35
P.O. Box 1504 VOICE (760) 777-7012
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number: ( I Date: 1 g' 1510q
Applicant:
0l✓/V I--- 2
Applicant's Mailing Address:
Architect or Engineer:
Architect or Engineer's Address:
Lic. No.:
BUILDING PERMIT DECLARATIONS
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 Professionals
Code, and my License is in full force and effect
License Class License No
Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am axempt from the Contractors' 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 forthe permit to file a signed
statement that he or she is licensed pursuant to the provisions cf the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of D€visIon 3 of the Business
and Professions Code) or that he or she 1s 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 civII penalty of not more than five hundred dollars ($500).):
U 1, as owner cf the property, or my employees with wages as their sole compensation, wl€1 do the work, and the structure is not intended or offered for safe (Sec. 7044,
Busgtess 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
hlmself or herself or 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.).
U I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professlons 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
Oate r 1 Owner w -rA F 5LA FLA 7—A
WORKERS' COMPENSATION 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 3700 of the Labor Code, for the performance
of the work for which this permit is issued.
I have and wlll 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 Insurance carrier and policy number are:
Carrier 141RHW SuR.7 5TA-rC FUNID Pollcy Number t 7-e 5 I d
I certify that, in the performance of the 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 that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall
forthwith comply with those provisions.
Date tt�l5/o4 Applicant ,
WARNING: FAILURE TO SECURE ❑RKERS' COMP SATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($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.
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 far whose benefit work is performed under ar 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 hermIass the City of La Quinia, its
off cars, agents and employees far 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 county ordinances and state laws relating to building
construction, and hereby authorize representatives of this county to on er upon the above -mentioned property for inspection purposes.
Date 1 Y I S/O 4- Signature (Applicant or Agent):