08-1803 (SPIN)4
P.O. BOX 1504 VOICE (760) 777-7012
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: 10/31/08
Application Number: 08-00001803 Owner:
Property Address: 81822 VIA SAN CLEMENTE LA QUINTA 57 TES C
APN: 764-010-008-73 -31910 - 78401 HWY 11
Application description: SPECIAL INSPECTION LA QUINTA, 2253
Property Zoning: LOW DENSITY RESIDENTIAL
Application valuation: 100 �! Q
7
Contractor: `wry? ` <13"
Applicant: Architect or Engineer. HERINGTON DEVEi:,. ,�,NJAME'S Off
40960 CALIFORNIA 'OAI�S�,�28
MURRIETA, CA 92562x
(951)677-8415
09,11, \IA Lic. No.: 753190
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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: B license No.: 753190
Date: Contractor:
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the
following reason ISec. 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 Contractor's 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).:
(_) 1, 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 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.).
1 —) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.
7044, Business and Professions Ce: The Contractors' State License Law does not apply to an owner of
property who builds or improves th a and who contracts for the projects with a contractor(s) licensed
pursuant to the Contractors' State L e e Law.).
(_ 1 I am exempt under Sec. , BA for this reason
ate:.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that th re is a construction lending agency for the performance of the
work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name: •yam
Lender's Address:
LQPERMIT
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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 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 STATE FUND I Policy Number 1542746-2007
I certify that, in the perfo m ce of the work for which this permit is issued, I shall not employ any
person in any manner o s to become subject to the workers' compensation laws of California,
and agree that, if I sh I become subject to the workers' compensation provisions of Section
30 of the Labor Co I shall forthwith comply with those provisions.
ate ; O%pticant:
WARNING: FAILURE TO SECUREORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIM NAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS 15100,0001. IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
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, indemnify and hold harmless the City
of La Quinta, its officers, agents and ployees 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 ap lication becomes null and void if work is not commenced
within 180 days from date of issuance f s ch permit, or cessation of work for 180 days will subject
permit to cancellation.
1 certify that I have read this application and state tha t above information is correct. I agree to comply with all
city and county ordinances and state laws relating to u' ng construction, and hereby authorize representatives
of cou ty to nter upon the above-mentioned pro for inspection purposes.
Date , 3 ignature (Applicant or Agent):
Application Number
Permit . . .
Additional desc . .
Permit Fee . . . .
Issue Date . . . .
Expiration Date . .
. . . . 08-00001803
SPECIAL INSPECTION
100.00
4/29/09
Plan Check Fee .00
Valuation 100
Qty Unit Charge Per Extension
BASE FEE 100.00
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Special Notes and Comments
SPECIAL INSPECTION TO VERIFY SFD IS ABLE
TO BE FINALED. FINAL ORIGINAL SFD
PERMIT # 05-2783 IF ABLE.
Fee summary Charged Paid Credited Due
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Permit Fee Total 100.00 .00 .00 100.00
Plan Check Total .00 .00 .00 .00
Grand Total 100.00 .00 .00 100.00
LQPERMIT