0108-339 (BLDG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed uncle► 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
Date Signature Df 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, or my employees with wages as their sole
compensation, will do the work, and the "structure is not intended or offered for
sale (Sec. 7.044, Business'& Professionals Code).
( ) I, as owner;of the property, am exclusively• contracting with licensed
contractors to construct' the project (Sec: 7044; Business A Professionals
Codej. - .
O
lam 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 mairitain.a certificate of consent to self -insure for workers'
compensation, sas provided for' 6y Section 3700 of the ;Labor Code, for the
performance of the work for which this permit is issued•.
{ ) Fhaire and -will maintain workers': compensation` insurance, as'required by
Section 3700 of,the Labor Code, for the performance of Itie work for which this
permit is issued. My workerscompensation insurance carrier & policy -':no. are:
Camer Policy No:
(This section need not be completed if the 'permit valuation.is for, $100.00:or.less).
O I certity that in the performance otthe 4uork for which this permit is issued,
I shall not employ any person in any manner so 'as to become, Object to the
'Workers' compensation laws.of California, and agree'that if l should become
subject to the workers` compensation provisions of Section 3700 of the Labor
'-Code, I shall forthwi6comply 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 fQr in Section 3706
of the Labor.Code; interest and attorney's fees.
IMPQRTANT,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
perrriit.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#
DATE VALUATION LOT
TRACT
JOB SITE
APN'
ADDRESS
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OWNER
CONTRACTOR/ DESIGNER / EN INEER
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USE OF PERMIT
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
DAVE -STEAVENS
Inspectioin Services
,PROJECT 41-A k%E 1'C'
ADDRESS-'Yq ; Si39,6 7., S6, S'3
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BLDG. PERMIT #
ENGINEER 11 wnu%J Sia go F-, =.I C
INSPECTION TYPE
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PROJECT-#
CLIENTf�
DATE "R -C.&-1 -)-v 0 2—
ARCHITECT
AItCHITECT 6=008A -A 2 LvA
CONTRACTOR -�f:L. m A 2
IINSPECTIONj REPORT
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CERTIFICATION OF COMPLIANCE To the best iof our knowledge,�all-of the reported work, unless otherwise noted, l .
substantially complies with app'rov'ed plans,.,specifi'datlons and applicable sections of -the building codes. This -report covers
s� i`he locations of the work inspected-only.4nii:do",es not constitute_ engpeenng;opmion:or pr#ct,'control. {
CERT. NO. INSPECTOR NAME 3A
I
DATE 3 /VIA t CP/ oLDOZ .,INSPECTOR SIGNATURE � �-- �
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Page of 2—
DArVE STEAVNS
Inspection Services .L
PROJECT%C�P w �i�flS� t r. PROJECT'#
ADDRESS :.5"4-, 83 '7 7,16 5: -2.5 3._ CLIENT &,J' (AJ),— '.ST 14D/4
OAKN «L DATE ;
BLDG. PERMIT # ARCHITECT
:. ENGINEER ut_oJ til S J o t i a L CONTRACTOR _PL .111-41? 104 U
INSPECTION TYPE
-I-NSPECTIO'N, REPORT
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CERTIFICATION OF COMPLIANCE To the best of our knowledge, all.of the reported work, unless otherw)se noted,
substantially complies with approved plans; specifications and•applicable sections of,-the•buildino- es. This report covers
.the locations of the work inspected only, and does no constitute, engineer)n-) p)nlon'or.project control:
CERT. NO. O8S93 �B'- SV r •INSPECTOR NAME L t. �` �' �4 Jam S
DATEec Cv M �Z C W a 00 _ INSPECTOR SIGNATOR -• of
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Page 2 Z
DAVE STEAVENS:
(Inspection: Services
PROJECT rGA` W E S - r-�
PROJECT* a v6 a - C->,3
ADDRESS 5; 17 7 SG ;5,3. CLIENT.. b-4 o Pit
DATE. 12' rw A Vt .C-0 2,c; -c.) -z-
BLDG. PERMIT #ARCHITECT GOC r6 R P 2C_: -i
ENGINEER �u.n]n.� SAJoU ��L CONTRACTOR �. -C_ W1 f}#2. ('aft<< Ft c
INSPECTION TYPE
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INSPECTION,fREP-ORIT
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CERTIFICATION OF COMPLIANCE To the best of our knowledge, all of the. reported work,:unless otherwise noted,
ubstantially complies withapproved plans; specifications and applicable sections of the building;codes.Tliis report covers
the locations of the work ins ected onl and does hot constitute en Ineenn o In(on'or ro ect control.
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CERT. NO. INSPECTOR NAME �7i J�r A cJ c; ►J S . .
DATE 12 Zoo Z INSPECTOR SIGNATUR J
PROJECT t7G l �.J �T • t�NW5E` 1►3
ADDRESS S`i'- SB�t SGS. SS3
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BLDG. PERMIT #
ENGINEER) ,V.4--, Sfa
INSPECTION TYPE
PROJECT W <oZ Oo2 = O 3
CLIENT i�.Jc57
DATE `�..1 a iM� 2. C -t,4 a oy Z
ARCHITECT GOL43A AZC-H
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CONTRACTOR D6L MAIZ PA g r o
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 andapphcable sections of the; building.codes. This report -.covers
✓the locations of the work inspectedonly anc! does "not constdute.engineering-opinionor:project control.
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CERT. NO. Oe s-9 3 q9 5.0, INSPECTOR NAME. I .,4 Jt ✓ S
DATE INSPECTOR SIGNATU