04-5991 (SOTB)T44f 4 4 QgAraj
P.O. Box 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING PERMIT
Application Number . .
Property Address . . .
APN :
Application description
Property Zoning . . . .
Application valuation .
Owner
------------------------
SANTA ROSA PLAZA
7902 S DEPEW STE 120
LITTLETON CO 80121
BUILDING & SAFETY DEPARTMENT
(760).777-7012
FAX (760) 777-7011
INSPECTION REQUESTS (760) 777-7153
04-00005991 Date 9/03/04
50777 SANTA ROSA PLAZA
770-020-031-6-000000-
STRUCTURES OTHER THAN BUILDINGS
GOLF COURSE
40000
Contractor
------------------------
OWNER
--------------------------------------------------------------------
Permit . . . . . .
BUILDING PERMIT
Additional desc . .
Permit Fee
349.50
Plan Check
Fee
227.18
Issue Date
Valuation
40000
Qty Unit Charge
.Per'
Extension
BASE FEE
252.00
15.00 6.5000
THOU BLDG 25,001-50,000
97.50
Special Notes and Comments
-
FOUNDATION FOR HORSE
SCULPTURE &
MOUNTAIN BACKDROP
Other Fees
STRONG
MOTION (SMI)
- COM
-
8.40
Fee summary Charged Paid
Credited
Due
Permit Fee Total
349.50
.00
.00
349.50
Plan Check Total
227.18
.00
.00
227.18
Other Fee Total
8.40
.00
.00
8.40
Grand Total
585.08
.00
.00
585.08
P.O. Box 1504
VOICE (760) 777-7012
78-495 CALLS TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number: 011-5
Date:
Applicant: .�rchitect or Engineer:
Applicant's Mailing Address: 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 Glass License Nf)
Date Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from tale Contractors' State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
city a county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to is 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 Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business
and Professions Code) at 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 rive hundred dollars ($500).):
(_j 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. 70",
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 or through his or her own employees, provided that the improvements are not intended or offered for safe. 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 Cade: The Contractors'
Slate License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contractar(s) licensed pursuant to
the Contractors' State License Law.).
(, I am exempt under Sec. , 13A P.C. for this reason
-5Ant-rA K6 SM PLASA
�DateSlEly7 �Dy— _ORmer�t_[SISr2T 'E.1=9ZA r— �re.�fs�%
WORKERS' COMPENSATION DECLARATION
I hereby affirm under penalty of perjury ane of the fallowing declaralions
I_have and wi11 mainlain 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 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 insurance carrier and policy number are:
Carrier Policy Number
1 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.
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COV0AGE 1S UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,i}00), 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
IMPORTANT Appllcatlon is hereby made to the irector of Buildin andSa ett CKNOWLEDGEMENT
or a
D
1. Each person upon whose behalf this application is made. each person at we whose request and ject to efy whcond rose benefit work srestriction
under s set forth on I sof pursuant to any permit
issued as a result of I h i s application, the owner, and the applicant, each agrees to, and shall, defend, indemnify and hold harmless the City of La Quint a, its
officers, agents and employees for any act or omission related to the work being performed under or fallowing issuance of this permit.
2. Any permit issued as a result of Ihis 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 enter upon the above -mentioned property for inspection purposes.
lSignature(Applicant orAgent): GIs '
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CITY OF LA QUINTA SUB -CONTRACTOR LIST
JOB ADDRESS - PERMIT NUMBER ,-r OWNER BUILDER
This form shall be posted on the job with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this list or their employees are authorized to work
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failufe to comp y will result in a. stoppage of work and/or the voidance
of building permit. For each awlicable trade. all information renuesterl helnw mist hP rmm�intari h■, annlit-ant F"An Gila" is rent � o..*�{�ie e f'� _ 1.
Trade / Classification
Contractor
State
Contractor's License
Workers Co
mpensatioJ 1 surance
`�"f
City Business
License
Exp. Date
Carrier Name
Policy Number
Exp. Date
License Number
Exp. Date
Company Name
Classification
License Number
(e.g. A, B, C-8)
(xxxxxx)
(xx/xx/xx)
(e.g. State Fund, CalComp)
(Format Varies)
(xx/xx/xx)
(xxxx)
(xx/xx/xx)
EARTHWORK (C-12)
CONCRETE (C-8)
G��C3� E.►=�tn�
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4Z GI
� ?0 0
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1u�r.�rt. moo.
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109 �9
9/3o/a�
FRAMING (C-5)
STRUCT. STEEL (C-51)
MASONRY (C-29)
PLUMBING (C-36)
LATH, PLASTER (C-35)
DRYWALL (C-9)
HVAC (C-20)
ELECTRICAL (C-10)
ROOFING (C-39)
SHEET METAL (C-43)
FLOORING (C-15)
GLAZING (C-17)
INSULATION (C-2)
SEWAGE DISP. (C-42)
PAINTING IC-33)
CERAMIC TILE (C-54)
CABINETS (C-6)
FENCING (C-13)
u4NIDSCAPING (C-27)
POOL (C-531