0108-338 (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 # Lic. Class Exp. Date
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 thestructureisnot intended or offered for
sale'(Sec: 704'4,.Business & Professionals Code).
( ) I; as ,owner• of, the •property; am ezclusive,ly contracting with' licensed
contractors to construct.the project (Se'c..7044, .Business & Professionals
Code).
O 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"Jollowing 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 whi6'thispermlt Is Issued
()', I have and'vnll •maintainworkers' compensation, insurance, as required by
Section' 37,00 of't ie Labor Code, for the performance oPt.he work for which this
permiT is issued.'My workers' compensation Insurance carrier. &•.policy no. are:
Carrier Policy No.:A
(This, section need, not be completed if the permit valuation is for $100:00 or less).;
O I,certify that in the'performance of the' work for -which this permit -'is issued, .
1=shall not employ any person in. any°manner':so as to become subject to the
workers` compensation laws of Calrfornia, and agree that if I should become
subject to the workers'�compensation provisions of Section 3700 of the'Labor
Code, 1 shall forthwith comply with those provisioris.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $1*00,000, in
addition to the.cost of compensation; damages as provided for in Section 3706
of•the-Labor,Code, interest. and•attorneys.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.
BUILDING PERMIT
PERMIT
DATE VALUATION LOT
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L o c) 17
JOB SITE
APN
ADDRESS qf-7.1.1_•1!
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OWNER
CONTRACTOR/ DESIGNER/ EN INEER
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USE OF PERMIT
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7516)0 '11'. C:1AF•;.1::1•"I 1`F_•
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2-09000.00
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
r . Page of
DAVE STEXVENS
IIftV t ioW ervices
PROJECT ��A vJi 5'1 fl 5C ;g `' PROJECT
.ADDRESS %sZS1 �l 3f.�1 CLIENT t?Gf. " t;y.EST kof�
CA444I L L,. A4APj --T ,W4 D6, S_ DATE off: 8 .: it t3 moo Z
BLDG. PERMIT # ARCHITECT Goc"eA aQrzC,.{.,
ENGINEER" k eta S►9 -sn.!G_ CONTRACTOR'
INSPECTION TYPE
INSPECTION REPORT .,
k/C.4 r2 . n l A i J�., -A Q T)' S T 2
L E Tc
F r. Loc. - 3 _ _
CERTIFICATION OF COMPLIANCE To the best of ourknowledge, all -of the reported work,unless othervvlse.noted,
substantially complies with approved plans, specifications and 'applicable sections building codes. This' report covers
the locations of the work inspected only and does -not constitute enguieering opinion or project control.
CERT. NO. D�3s'9" 4�B':5O INSPECTORNAMEAVE+JS
/� I� ..�:• i 'r..ty 5', ti f11C188f1y) - ..
DATE oZ D L' /J eZ oO'Z INSPECTOR GNATURE` a
. SIN y I
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Page of
DAVE STEAVENS
`Ingpection' Services
PROM CT-�Lf+ , : QST t�N'ASE X43 PROJECT'#: o?oo,,Z
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INSPECTION TYPE t
INSPECTIONREPORT'
S 55-5
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CERTIFICATION OF COMPLIANCE-'.7dlhe best of our knowledge, a-Wof the reported work, unlessotherwise noted,
ubstantiall complies with -
y p approved plans, specifications and.applicable sections of the building. codes. This report covers
the locations of the work inspected only and does not constituteengineenng opinion. or project'control.- ;
CERT. NO. ��Q� R S •'� : INSPECTOR NAMEY AJ
�1` A✓ESS • , ..
DATE aLmEB aUO.Z INSPECTOR.SIGNATUA '`'
Pae l of 1
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DAV� STEAVENS , Page
I�nspection�Servc,es
PROJECT A E'-, i PROJECT # • .^ .vo Z. -0 3
ADDRESS a �.a�*� `�h 11 CLIENT ° G.A SEs % deo,}
DATE l M -A 2 ayo .1,
BLDG. PERMIT # ARCHITECT GDLB.}.(ZC4
ENGINEER tui 0 rJ S A j0,e CONTRACTOR AE M4 2 P'Icl e=1 L
INSPECTION TYPE
INSPECTION _REPORT
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CERTIFICATION. OF COMPLIANCE:To the bestof our knowledge, all of the reported work;:unless otherwise noted, P '
substantially complies witfl approved plans, specifications and applicable sections of he.building;codes.This reportcovers
the locations of the work inspe' 6i `only and does`not constitute engineenng'opinion or project;control.-
CERT. NO. OS �I`/'38`J V 4 i
YINSPECTOR NAME A SriA A� Q
a
n
DATE �i�'C ' UV Z�, INSPECTOR S ._ ., io�`, y; 1;
IGNATU
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DAVE STEAVENS . -
Inspection. Services
.. PROJECT ,P(=. A �k)L5-r-
N A S c( a
ADDRESS ,Sy 37.
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BLDG. PERMIT #
ENGINEER
f A J o i e
INSPECTION TYPE
1
Page i of _
PROJECT #
CLIENT
DATE A50 FCyo Z
ARCHITECT Gy L 8A4 X t?W) reC-Tu,zE
r CONTRACTOR e -L r`^'A (t
INSPECTIONREPORT
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CERTIFICATION OF COMPLIANCE To the best _of our, knowledge, all of the reported work`unless otherwise noted,
substantially complies wlth,approved.plans specmcabons and applicable sections.of the building. codes. This report covers
the locations of the work inspected only and does` not constltute:dnglheering opinion orproject control:
CERT NO. [S 5 73 'f g Sw.. .yam= J
INSRECTQR NAME' .` I / S/, �1
,. INSPECTOR SrGNATURE