0108-353 (BLDG)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 k Lic. Class Exp. Date
73"x152 D 03/3,;12(
Date Signature of Contractor
OWNER -BUILDER DECLARATION
hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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 & Professionals Code).
( ) I, 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
Section 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:
CartierPolicy No.
GAL It:C.�l;�t71`i"r I -4306217'F:
(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
Code, I shall forthwith comply with those provisions.
Date: 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 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 t 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
O;truction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
I Signature (Owner/Agent)
Date
BUILDING PERMIT PERMITq
DATE VALUATION LOT 0108--353 TRACT
$70,00(1,00
JOB SITE
APN'
I
ADDRESSOAK INLI,
OWNER
.CONTRACTOR/DESIGNER/EN INEER
F'CI'_ °aIf✓:I'T �? ;: i� ;f ' ' � , `S�=t 'F:11C. r3
)EL MAP.-PACIRC TEKEY AL CONTRACI*0 _
I i iLILKI 1 t_f'. -l[;L?3
SOLAlVA BEACH %A 4[01.5`;
!Q5fi)7s°?-;500 C.
t-QI,OFFICEDIFORMATION
15823
m"
USE OF PERMIT
75.1611 3'". ;=HArL.E" PL
54.0611 54.057, 54-0�5-"a�&'=54.049 OAK HILL,• BUILllI[dC 20 TYPN:
'�'• '
1(iC JC?1_.l!T7'1'A,.^n.y S? ht1C:T!IFAL. 5/j()r31F
'<5
ESTUVIAT.ED COST OF CONSTR.UC:11ON
20;000.00
PERMIT FEE SUN110 . Y
C ON 1'! U1-Tir_tt; FEL 1(?] 0G0,.,4.1s.13U0 Y2(1i,UU
STRONO MOT1014 FEE • DESID liJl-Q00-24'1-006
ir�.•_ ..<_.-i"•u1;1 ClE.CK
X0 . CC
LF_ZS PARE -PA. FEES
TOTAL DUE- NOW
$709.00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
Page l of..,
DAVE STEAVENS
Inspection Services
PROJECT } 1" WE 57- PWN-zE t J9 PROJECT # .2 6>0 z
ADDRESS. CLIENT ?GA u3c-"i Mo Fx:
Z_ 0 DATE c,2 3 A P R
.-,...BLDG. PERMIT # ARCHITECT ('r>e-6A
.�'ENGINEER-,butgt,) SAjott?j k c PAC -i F ic—
CONTRACTOR A. /Z
INSPECTION TYPE
INSPECTION REPORT
tS -7, 05 ti 49 oAr HILL L 0c.
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14 FLA(?- tiJ A I L I
40L le, # /2.
CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
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. L)
INSPECTOR ��R NAME
(Pr
DATE 62 3 _-2 C.X? INSPEGTOR SIGNATURE_7�
Page f of
DAVE STEAVENS
Inspection Services j
PROJECTfl.SS • i�al;�S� l3
ADDRESS Sy - o<. 1,6 5 10 o S 3+ o y S
BLDG. -PERMIT #1. '
ENGINEER" Q tj S A jU ( t_ —_Z7,,.I e
INSPECTION TYPE
PROJECT # :200Z-0-3
CLIENT PGA W t 5 i 040A
DATE o' A ?2 r L_ 20o Z,
ARCHITECT 6,64-6A A ec s-1
CONTRACTOR �U-c ^,9,e d,gcr r r c
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
substantially complies with approved plans, specifications and applicable sections of the building codes. This report covers
J the locations of the work inspected only and does not constitute engineering opinion or project control.
CERT.NO. INSPECTOR NAME 2E S e f4 dE JS
DATE INSPECTOR SIGNATUR
DAVE STEAVENS
Inspection Services
PROJECT(=.P �� s - W�iSa✓ t
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ADDRESS S4 - 0(o r, 0 571, 0 S 3.0 y q
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..INSPECTION TYPE
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CLIENTS
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CONTRACTOR
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
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,% the locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. NO. Q 8 Sy 3 gig - , y INSPECTOR NAME ` 3 A i C tC14 )c "J!5
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DATE Cb INSPECTOR SIGNATURE
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Inspection Services
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BLDG. PERMIT #
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DATE
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INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
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the locations of the work inspected only and does not constitute engineering opinion or project control. i
CERTAO. C>e 57 3 p ' INSPECTOR NAME , C
DATE
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
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. i
CERTAO. C>e 57 3 p ' INSPECTOR NAME , C
DATE
17e 14/2 l L (20 2- INSPECTOR SIGNATUR�a�.