0108-337 (BLDG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 0 (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
73IJl, r?
Date Sighature of Contractor
OWNER -BUILDER DECLARATION
Thereby affirm under penalty of perjury that tam 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, andthe structure isnot intended or offered for
sale (Sect'M44; Business & Professionals Code).
( ) '1= as owner of tlie property, ,am `exclusively contracting. with licensed
Contractors to, construct the project (Seca 7044, Business & Professionals
Code).
i � L
O I am exempt ;under Section ... B&P.C.,for this reason
. Date -Signature of Owner
WORKER' S'COMPENSATION DECLARATION
I hereby affirm. Linder .penalty`of perjury, one of the following declarations:
O ) 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•iorwhich this permit -is issued.
( ) I have and will' maintain workers' -compensation` ins;J ance,.as.required by
Section 3700 of the Labor- Code for the performance of the w"ork for which this
permit is issued. _My workers compensation insurance carrier &; policy'no. are:
Camer Policy No.
Si
(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;
I shall not employ any person imany manner so as to become subject to,;the
workers' ;compensation laws of California; and*:' 'agree that, if, Ishould become
subjectjto°the Workers'' compensation provisions of:Section 3700 of the Labor
Code, I shall forthwith'comply with those provisions.
Date: Applicant _ x..
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shalf`subject'an' employer to criminal penalties and civil fines up,to.$100,000, in
addition to. the cost of dompensation, damages%s provided for in Section 3706
of the.LaborCode,•interest andattomey's fees!--
IMPORTANT
ees 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.
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#
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ADDRESS
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
DAVE STEAVENS
Page of
Inspection Services
PROJECT (, k t,.N E s -c IW1WOA�C ' 14 PROJECT # a U o 1'- O 3
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BLDG. PERMIT #
ENGINEERS)L,,a-*) fj' o jg«:: i tic -
INSPECTION TYPE '�.
CLIENT_�(,,k
DATE ei 1 '5tEg 9 O
ARCHITECT � LZ A A 2 e W,
CONTRACTOR )eL vh A fL PAc (ri L
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
the locations of the work inspected only and does not constitute engineering opinion orproject control.
CERT. NO. 0,95✓ 93 1/8 — 5`0
DATE s� F j g •'Z vo 2.
INSPECTOR NAME) S't►Ir a J� a 5
INSPECTOR SIGNATURE
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Inspection Services
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BLDG. PERMIT #
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INSPECTION TYPE EPoi--f
DATE (q rE )3 a .. vo Z
ARCHITECT GoL $R f�ZC-N �i-Tv2c
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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 applicable sections of the building codes. This report covers
0,111the
locations of the work inspected only and does not constitute engineering opinion or project control.
ERT. NO. U S S9 3 4 — 75 INSPECTOR NAME .1 4I E EA ✓ 1.1
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DATE' INSPECTOR SIGNATURE� 1
C-1
Page of I
DAVE STE
.. AVENS
Irispeetion Services .
PROJECT -?6A
ADDRESS �,Ly� `}+ 5' ri
'.BLDG. PERMIT #
- ENGINEER �)ui rJ J S A JOie T_J C-
INSPECTION TYPE
PROJECT # a vo .Z -0 3
CLIENT PGA +-cit 5 % k1eA
DATE
ARCHITECT CSL a A 2C,4
CONTRACTOR (Z �G► r= i L .
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,* 'd plans; specifications and'applicable sections of'the building. codes. This reportcovers . 1
,substantially -
locations of the work ins 'ected `onl and does not' en ineerin
P Y g g opinion or protect control.
CERT NO. O S3 5 9 T:g' J Cj s.: ' INSPECTOR NAME , + �J S eA:✓
,. .=n � • - - t+ 4 rt Pent Clear � _
-,DATE
INSPECTOR SIGH U