9803-187 (SFD)LICENSED CONTRACTOR 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 # Lic. Class Exp. Date
4 6/30198
I/ate Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is riot intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S 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 will maintain workers' compensation insurance, as required by
Siktion 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
NIPKrjg FUM) 035-97-1230
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) 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
xl'�e, h comply with th e p sions.
ate: Applicant—
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $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.
IMPORTANT Application is hereby made to the Director.of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
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 applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void it
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 State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
/Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT # CONTROIL#
980X.1 87
DATE VALUATION $180,490 .0j) LOT .5 TRACT 8,,._7,L8
iq IC4
4 �-
JOB SITE'l " '
APN
ADDRESS 78-690 CASTLE PINES DR.
769-740-00-5
OWNER
CONTRACTOR / DESIGNER ENGINEER
PUT HOMES LLC
RJT MESTIMMIS3, INC.
'P.O. BOIX810
1425 E, UNIVERSHY DRIVF
LA QUINTA CA 92253
PHOENM AZ 95034
(60T)257-1656, CBL# 4990
USE OF PERMIT
,�'F D
PLAN 8FD -.RJT HOWES @ LA QUMA FAIRWAYS - 75,1/o PLAFpAJr%
CRECKREDUCTIONAPPLYED
APR 1)
9 1�3�38
CUMDTWCONSTRUCTION 2,1,80.0 SIT
PORMPALT10 ',0.00 sFogyl OF
LA, QUINTA
GARAGFJCAP.P ORT 490,00 SF
4
ESTIMATED COST Or, CONST RUCT [ON
PERMT FEE SIMCNIARY
CON STRUCTf ON FE E 101-000-418-000 $9.23-00
PLAN CffECK FEE 101-000-439-318 S189.82.
WX-14AMICAL FEE 101-000-421-000 $98.50
ELECTRICAL FFX 101-000-420-000
PLUMBING FEE 101-000-419-000
3'rRaKo MOTJON� FEE - RE -3.0) 101-000-241-000
GRAWNG FEE 101-000-42-1-000 $20.00
WRASMUCT Mri YU 2-2.5-M-443-342 34,037.09
ART IN PU81.1C,P1,AMS - IMSM 7011--000-255-000 S201.23
SUB-10DAL COXSTRU MON AND PLAN CH L, CK
LESS PR:B-PAtDFEE$
$(M)01
TOTAL PE RAHT FEES DUE NOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR