0108-343 (BLDG)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under.penalty'of perjury that I am licensed under provisions of
H Chanter 9 (commencing with Section 7000) of Division 3 of the Business and
LU Professionals Code; and my License is in full force and effect.
&) ``i License # Lic. Class Exp. Date
!ni
Date 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:
( ) I, as owner of the property;' br 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). `
O I am.exerriprunder Section B&P.C. for this reason.
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of,periyry one of the following declarations:
O 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.
( ) l,have and will maintain workers' compensation insurance, as required by
Section 3700 ofAhe I Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
CarrierPolicy;No:
�.r.1'.iic:%i�•r4ii4li
This section need not be completed iFthe permit Valuation is for $100100 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 Califomia;'and agree that if I should become
subject to the workers' compensation provisions of Section. 3700 of the Labor
Code, ( 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 $100;000,,in
add, ition.to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT 'Application is hereby made to the Director of Building and Safety .
for, a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is.performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon.
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT
PERMITq
DATE VALUATION LOT
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JOB SITE
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ADDRESS
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OWNER
CONTRACTOR / DESIGNER / EN 1NEER
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
DAVE STEAVENS
Inspection Services.
'. PROJECT: GGA WEST- tW RSc 03
ADDRESS SY- 385373, 3C,1; 349
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BLDG: PERMIT #
ENGINEER , Jo I E =►j C.
INSPECTION TYPE Eley
Page of o1.
PROJECT #`offyC>2 - 0 4
CLIENT I� SA �EsT" f 4 o r4
DATE I$. OAP P-CIr{ -a0,02_
ARCHITECT,'601-804. /}(LCI-/
CONTRACTOR cL. A -pi %L P,4 ci Fi 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 plies with approved plans, specifications and 'app licable sections Uthebuilding codes. This report covers
,ihe locations of thg work inspected only and does not constitute engineering opinion or project'control.
GIRT. NO. -9 'T g` S G S INSPECTOR NAME 1
• �,
DATE J �� C 0906 WNB TORSIGNATUR '
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Page of t
DAVE STEAVENS
Inspection,. Services:
{ 'PROJECT ��A �1� t��l�5t-1Q PROJECT- # 61 oo.2. U 3
:':ADDRESS. '13�� C. i-.1 a CLIENT W A. I.J 4�- 5T H o 4
DATE C.) a 2
.BLDG PERMIT* ARCHITECT Gv'` ZP4 A tZcW
ENGINEE1i1t_,0 ►JSAJ o a L CONTRACTOR J;e L m eq,
INSPECTION TYPE
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.witWappioved plans,.specification`s and applicable sections.of the building codes. This report covers
the locations of the -work ins pected:only and does not constitute"engineering opinion or project control.
S
CERT.N0.. 09 54'3 �e - SD r 4', 1NSPECTOR NAME �J'A ✓E,. r S �F09 ►•� S. �
' DATE, �`I A,4 e C /-/ o� DD Z' ' `INSPECTOR SIGNATU 3