0108-335 (BLDG)LICENSED: CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that l'•am licensed under provisions of
F- ~' Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W 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, as owner of1he 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).
( ) I, -as owner of the property, am :exclusively, contracting with licensed
contractors to construct the project (Sec. 7044;' Business &' Professionals
Code).. .
O Iam e'xe.rript underSection 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 ma intain'a certificate of consent to self -insure for workers'
compensatlon,:as provided for, by Section 3700 of the Labor Code, for the
performance ofthe work for whichahlsApermit Is Issued."
(,) . I have.and will. maintaln.workers' compensation ins'Urance, as (equired by
Section.3700'.of-the Labor Code,`for the performance of the work for which this
,permitris issued.: My workers' compensation,msurance canier: &;policy no: are:
Policy'No.
(This sectiomneed hot -be completed ifdhe 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 in any manner so ,as to become: subject to ;ttie
workers' compensation laws of California, 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 provisions
Date: ;Applicant -
Warning:,F.ailure to.'secure Workers' Compensation coverage is •unlawful and
shall subject.an employe[ to criminal:penalties and civil fines up fo'$100 OOO; in
addition to the cost of'Ccnlpens ation, damages as provided for in Section 3706
of`the'Labor`Code; interest and-attorney'sfees.:
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth'Zon 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 PERMITN
DATE VALUATION LOT C'ti iiS k3 TRACT
S;7CI j i3.€;10
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN 1NEER
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CERTIFICATION OF COMPLIANCE To the best of our knowledge, all''of the reported work,Munless otherwise noted,
,.
substantially complies with' approved plans; specifications and `applicable sections of-the building codes. This report covers
the locations of the work ins-spected only and does not constitute engineering opinion`or project control.
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CERT NO. _�3:5. 93;R ' 'D ' ..INSPECTOR NAMEM�,tc lea
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4' DATA sZ Fc �"� �:y U. Z INSPECTOR SIGNATU
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Page bf_
DAVE .;STEAVENS
Inspection. Services
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PROJECT�N v.�L ST - i�N�, SE (� PROJECT #
:'ADDRES9'5 1(,16I rVVb qp5 i CLIENT
W" JLb DATE ll= ,it L ' .1 ,00 --k
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BLDG PERMIT # rtc. ARCHITECT L a A A iT�:ceF
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ENGINEER�ws,1..1 S�.Jn `�� L GONTRACTORE
--INSPECTION TYPE ,
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE To the best -of ourknowledge; all of the; reported workunless otherwise noted,
substantially complies with approved plans,
`spec icatlons aniirapplica6le sections of, the building codes. This report covers
the locations of the work -inspected only and does not constitute; englneenng opinion or project control.*,
CERT. NO. OSS 9 3 y'Qj+ �, ti D. !' i +.-'.INSPECTOR',NAME t � A,l` y r A. E: �] C
DAT7= _%I- E R INSPECTOR SIGNATOR . r r
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DAVE, STEAVENS
Inspection Services ' .
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PROJECT<c �' vJES ISS E .1
ADDRESS 'any 7� 9 79/ #7 F3 r .13 O
BLDG. PERMIT #
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". ENGINEER
INSPECTION TYPE
Page 1 of
PROJECT # of 0 2 - 40 3
CLIENT -
DATE
ARCHITECT 6043A ttRG-1 / TE e-7 -am"`
CONTRACTOR I -C4. m, AR ? .1471 c
INSPECTION REPORT
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DCERTIFICATION OF: COMPLIANCE. -.715616 best of our knowledgeall of the reported work, unless otherwise noted,
substantiall' complies.with approtied plans, specifications and�applicable sections of th'e�building codes. Tfiis, report covers
the locations of the work ins ected'on �,.
p ly and does not constitute engineering opicnon;or protect control..'-
CERT.
ontrol "CERT. NO. �S/.J O INSPECTOR NAME_ � k- „ -.A i E tJ S
DATA /' C.c7 .. o� OD Z INSPECTE�RSIGNATURE Ods— ..._
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CERTIFICATION OF COMPLIANCE To the best of our knowledge, all of the reported work,:unle'ss otherwise noted,
ubstantially, complies with, plans, specifications and applicable sections'bf*6 building. codes. This report covers
the locations of the work in- and does not coristltnte:englneenng oplrnori'or project control.
CERT. RIO.INSPECTOR
'NAME . {� " k ) -
�� e E
DATL INSPECTOR SIGNATOR _ :.