04-4281 (RER)�'I��lNrit/
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) 777-71.53
BUILDING PERMIT
Application Number 004-.000042-8.1___`, Date • 5/17/04
Property Address; . 54027 SOUTHERN HILLS
APN: 1j775-101-034- - -
Application description . REMODEL - RESIDEN,TIAL
Property Zoning-. LOW DENSITY RESIDENTIAL
Application valuation . . . . 8000
Owner Contractor
-- - - - - - - - - - - - - - - - - - - -
- -------- - - - - -- - KI--
PGA WEST RESIDENTIAL ASSN. INC OWNER -
D
.54320 SOUTHERN HILLS
LA QUINTA CA 92253 -JUN 04 2004
--------- ----- --------- Structure Information --- 7r--7 CrM0F_LA_QUWA
Construction Type . . . . . TYPE V - NON RATED FINANCE DEPT. '
Occupancy Type .
. . . DWELLG/LODGING/CONG <=10
.Flood Zone .. . .
. . . . NON -AO FLOOD ZONE
Other struct info
. . . . . CODE EDITION
2001.CBC
Permit . . . . .
-----------------------
. BUILDING PERMIT,
Additional desc
=°
Permit Fee
991 00 _ ` Plan Check -'Fee--.
.. 00
Issue Date . . .
. Valuation . . .
. 8.000
Qty Unit Charge Per
Extension
BASE ¢ FEE
., ., 45..00
6.00 9..0000 -THOU BLDG'2 0'01-25,000
54.00
Special Notes and
----------------------------=---.
Comments
VOLUNTARY SEISMIC
STRUCTURAL,REPAIR&.
---------------------------------
--------------------------------------------
Other Fees ...
STRONG MOTION (SMI) - RES
.80
Fee summary
-----------------
Charged Paid Credited
----------
Due
Permit Fee Total
------------------------------
99.00 .00 .00
99.00
Plan Check Total.
00 .00 .00,-,
.00
Other Fee Total
.80 .00 00``
80
Grand Total
99.80 .00 .00
99.80
V
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a .. K • .. A '
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P.O. BOX 1504
VOICE (760) 777-7012
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153
Application Number:
Applicant:
Applicant's Mailing Address:
BUILDING & SAFETY DEPARTMENT
Date:
chitect or Engineer: //11&
Architect or E ngineer's9Ad�dres
•� �. q
Lic. No. Clg3�q
BUILDING PERMIT DECLARATIONS
LICENSED CONTRACTOR'S DECLARATION
1 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.
Date Contractor
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
tr0 applicant to a civil penalty of not more than five hundred dollars ($500).):
Ail'tSC I, as owner of the property, or my employees with wages as their sale compensation, will do'the work, and the structure is not intended or offered for sale (Sec. 7044,
Business and Professions Code: The Contractors' Sate 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 . d Owner
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 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 nurtyper ire``:
Carver 61"A —IF Policy Number 1 s a,
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• 4. t7�—,Fplicant
4at
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 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, indemnity 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 county ordinances and state laws relating to building
construction, and hereby authorize representatives of this county to ent r upon thUabo erty for inspection purposes.
/Date ignature (Applicant or Agent):
Page of � l
DAVE. STEA. ENS
Inspection Services
PROJECT �(�; PROJECT # 2 U C) 5
ADDRESS Soy o 211 r_,z) CLIENT_�(,;P' u-)!L5"t
LA' OL, t J P. C-:0, DATE 3 .. S e' : 2: y d. 5�
BLDG. PERMIT# Ok- 4 7. Q 1 ARCHITECT `A .
ENGINEERCONTRACT OR
INSPECTION TYPE
INSPECTION REPORT
:FOLLOWING LOCATIONS EPDXY SUvIPSON: ETF. EXP. 1 � - y 5 HOLES DEPTH CHECKED,
BRUSHED AND CLEAN OF DEBRIS. APPLICATION, AND INSTALLATION AS PER. ICBG 4945..'
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rk)C_ MAGI-bu�A(Lf. ..l-�.l�u�Arto�: S�r�� Q+R��tcJ` • t�'w,1L_3^-rC
CERTIFICATION OF COMPLIANCE;'To.ihe best of our knowledge, all of the"reported work, unless otherwise noted,
0 substantially complies with approved plans, specifications and applicable sections of the building:codes.This report covers
the locations of the work inspected only and does not constitute engineering opinion or project control:
CERT. NO. 0859348-50.1 C -g. INSPECTOR NAME DAVE STEAVENS
(Print Clearl )
DATE (S� OCT 'Zoo S INSPECTOR SIGNATUR
E .�
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