BLCK (04-4616)BUILDING & SAFETY DEPARTMENT
P.O. BOX 1504 (760).777-7012
78-495 CALLS TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTION REQUESTS (760) 777-7153
BUILDING PERMIT
Application Number . . . . x-04-00004616_.-- Date
Property Address . . . . . -5r6,8'0 uAVENIDA NAVARRO
APN; 773-145-009-16 -000000--
Application description 'WALL/FENCE
Property Zoning.. . . . . . . COVE RESIDENTIAL
Application valuation. . . . ` 6375
5/26/04
Owner Contractor
DIROMA MICHAEL BIRDSELL BUILDERS, JOSEPH
P 0 BOX 41,616 35558 SUMMERLAND AVENUE
SACRAMENTO CA 95841 PALM DESERT CA 92211
(760) 409-0707 .(760.) 360-2301
C>='WCC: DAUGARD INS
�'WC: 22946491 11/01/04
c CSLB: 811293 08/31/05
c. CCC B
Permit WALL/FENCE PERMIT
Additional desc
Permit Fee.,...,.. 90.00 Plan Check Fee .00
Issue Date Valuation . . . . 6375
Qty. Unit Charge Per Extension
BASE FEE 45.00
5:-00 9. 0000 THOU BLDG 2.,001-25,000 45.00.
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Special Notes and Comments
255 LF 6' BLOCK WALL PER CITY STANDARD
Fee summary Charged
----------------- ----------
Permit Fee Total 90.00
Plan Check Total .00
Grand Total 9000
Paid
Credited
00
00
00
Due
90.00
.00
90.00
P.O. BOX 1504
Y
78-495 CALLE TAMPICO VOICE (760) 777-7012
LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7011INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number:
Applicant:
Applicant's Mailing Address:
Architect or Engineer:
Architect or Engineer's
Lic. No..
t3UILUING PERMIT DECLARATIONS
Date:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that 1 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�l(ull force arAeffect.
License Class�j$ / License No., Z �/ 3
Date 2 C^ G Contractor G-_�,i p u J?I:?Z/D,Si
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt 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 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) 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).):
U 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 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 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.).
U I am exempt under Sec. , BA P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
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 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 a�r .
Cartier D/,u 6A n /7 /A, -,S Policy Number 2 L q
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 S-26-0.4 4 Applicant G3�?/D / Yi1l��a LL (,j C4/e_ 04.
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 ($100,000), 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 penally 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
Lenders Address
IMPORTANT Application is hereby made to the Director of Buildin APPLICANT SCKNOWLEDGEMENT
1. Each 9 Safety Apermit subject to the conditions and restrictions set forth on this application.
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, indemnity and hold harmless the City of La Ouinta, its
officers, agents and employees for any actor omission related to the work being performed under or following issuance ofthis I.
pemu
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 pernit or
cessation of work for 180 days will subject permit to cancellati
I certify that I have read this application and state that the above information t rect. I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives of this c`unty to enter u ne above-mentioned property for inspection purposes.
Date's --76 -6q Si nature
g (Applicant or