0108-338 (BLDG)LICENSED CONTRACT013 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 # Lic. Class Exp. Date
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,
eason:'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).
as..ownei of!the' property,''am exclusively contracting with' licensed
contractors to construct Ahe..project (Sec. 7044; Business & Professionals
Code).
O l' ani 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:
(:) Fhave 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
Worth ce"of the work4or which this:permitis issued'.
( ) 'ftiave'and will; maintaln'workers�:compensation' insurahce�as,required by
.Section 3700: of; the Labor.'Code; for the performance of thew& for which this '
permit is issued.' My workers' compensation insurance ,carrie L& policy no. are: .
Carver: Policy No.
„4_(Thls section need not be completed rf the permit valuatlori is for $100.00 or legs).
O I certify that in the.performanceof the work for which:this permit Is issued,'
I shall not employ anyipe(son. in. any manner so as to become subject to the
workers' compensation laws of California'and agree that if I should become
subjectto.theworkers" 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 -end
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. „x
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.
BUILDING. PERMIT PEf;M1T#
DATE VALUATION LOT �I tJ ' 3 {> - TRACT
JOB SITE
APN
ADDRESS , sry
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OWNER
CONTRACTOR /DESIGNER / EN (NEER
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USE OF PERMIT '
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RECEIPT
DATE
BY DATE FINALED
INSPECTOR
Page 7, of
`DAVE '-TEAVEN.S.
Inspection- Sem"ce.0
PROJECT �Gki�'E57 PqA_5c�1-6
ADDRESS .TV, $ /lo t
'.-BLDG-. PERMIT #
ENGINEER lugjtil :;:�'c
INSPECTION TYPE'
PROJECT
CLIENT PGA. L, -)Es -r
DATE _C7 0 0G:
ARCHITECT C=0426A. Arz.CH,
CONTRACTOR
CERTIFICATION OF COMPLIANCE :T6the best.of ourkno'wedge:,: all ';"of.th6't6porto!.�vork,:yhless otherwise noted,
substantially complies with approved ,.... . icationsiland-ap
plan's,.spepif plicable, sektibris.-cif.,the- building codes.- This report covers
the locations of the work inspected 'only and does hottit t ,,
cons u e.�ngineenng opinion -or projectcontrol.
CERT. NO. 57 INSPECTOR NAME'. 0--S+k 'A
jrv OrInt
'DATE .1 8 A200z INSPECTOR SIGNATURE
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Page ( of l
:DAVE STE_ AV'",
Inspection Services
.`;PROJECT &,fl, :,)C:ST. - tom- NRSE t8 PROJECT*-- . o?oo,'t. -0 3
CLIENT,• e-. 0,t,,� C,S �y 14c
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BLDG. PERNUT # ARCHITECT G,oLb A A 2G4 tixc, u2c
ENGINEER �H t4 i �Zt' i,�i t �Z CONTRACTOR t
"INSPECTION TYPE
INSPECTION, REPORT -u
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CERTIFICATION OF COMPLIANCE To the best of our knowledge, all of the reported work,`unless 'otherwise' noted,
ubstantially 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 coristltuteengmeenng oplrnon or project control.
CERT. NO.
���4•-3 �R -•� 0 r. INSPEC,TORNAME � Kat.,`7`'✓ESS •
DATE Lo f -E 6 4? UO Z INSPECTOR SIGNATUA
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DAVE STEAVENS
Inspection Services
• PROJECT `'tj PROJECT N ,.a,yd Z
ADDRESS.' . 37_' 4. Z•�-- e CLIENT FP(A .Q, e.5 -r: Wo 4
DAKN ALL13[.D�� 5 P'+q" DAT .
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BLDG. PERMIT # ARCMTECT-Gy L 6Ar4(? W) Te c ry r2E j
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ENGINEERS Sri J o e 7WIL- c. CONTRACTOR `Cl- r" A R
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 with approved plans;£ specifications and 'applicable sections of the building.codes.Thls reportcovers
the locations of the work inspected'only and doe's`not:constrtute,engineenng opinion;or project:control.
CERT. NO.INSPECTOR NAME - 1 " ✓'.. ...J7 ✓�'r.1.� ;
='DATER SIGNATURE '
DAVE YSTEAVENS�
Inspection Services
PROJECT ?t;.A
ADDRESS
BLDG: PERMIT #
ENGINEER l(WItJ SA.JDii� 1-,J.4
INSPECTION TYPE
Page l of I
PROJECT #,
C UENT:
F
'DATE ~ I �►'� i4 iZ ago `a.
ARCHITECT 6;-0 aA 4 aC4
CONTRACTOR'EL M A 2 PAGi F/ L
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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,
substantially complies with approved plans, specifications'and,applica6le 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. I = 59 3 y l ", V ' INSPECTOR NAME 1 ' �> S'/, LA:
rmt Clear
DATEcVy Z • INSPECTOR SIGNATUA