0108-334 (BLDG)LICENSED CONTRACTOR DECLARATION
I Hereby affirm under penalty of perjury that.1 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. 51
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 of;th'e property, or my employees with wages as their sole
compensation; will do:thework; and,the structure is not intended or .offered for
sale (Sec: 7044; Business & Professionals Code).
as owner of the property, am exclusively contracting with,licensed.
Contractors to 'construct the project'.(Sec. 7044, Business & Professionals
Code). J
(.)• I am exempf under Section-` B&P.C. for this. reason
Date Signature ofOwner
WORKERS COMPENSATION DECLARATION,.
I. hereby affirm •under penalty::of perjury'„one .of the .following 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 tabor Code, for the
`p 6rmance of,the'work'.for which this,;permlt is issued
O 1.have.and will 'maintain workerscompensation insurance, as required. by
Section 3700 of•:the. Labor Code, for the irfe r ”' ': of •the -'work for'which this.
permit is issued: -My workers' compensation: insurance • carrier `& policy no. -are:
Carrier - Policy No.
C.A.) s )re !
(This -section need not be completed if the permit valuation is for $100A0,or less).
(.) I certify,that in.the performance, of the work for which,this permit is issued,
I shall'not.ernploy any person in_.any manner so as to become subject to the
workers' compensation •laws. of California, and agree that if I should become
subject toahe workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwithcomply 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 to1100,000, in
addition•to the cost of compensation, damages as. provided for in Section 3706
of the LaborCode; interest and attorney's 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 Ouinta, 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.
llofo
BUILDING PERMIT PERMITq
DATE VALUATION LOT G i C18-134 TRACT 46,
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$2.0,000,00
JOB SITE
APN
ADDRESS
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OWNER
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RECEIPT
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INSPECTOR
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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 sectio ns, 'ofthe building codes. This report covers
the locations of the work inspected'only`and does not constitute engineering` opinion or project control.
- CERT.NO. �i�S�%3�Ig'.S�C).
INSPECTOR NAME= '� `AJ.E-' S-/ EA ✓'E1J g
DATE / �� 02 U O �.
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INSPECTOR.SIGNATUR��.t.Le{ A"
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�DAV�E S & §EA:VE S
Inspection Services ;
_PROJECT�(,-..SEs � ��1�� x:3 PROJECT #yc5, 03
ADDRESS CLIENT �xA
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DATE'.. t r t g'
BLDG. PERMIT # ARCHITECT �, o 3:R 14�?cH r:recrucE
ENGINEER -b CONTRACTORS. ' L° nn A et Y r C
INSPECTION TYPE.'
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE 4To the besfof-our knowledge, all of thereported work; unless otherwise. noted'
,substantially complies with-approve specifications and:applicable sections of the: building:codes. This report covers
*:.
the locations of'the-work inspected only and does not constitut "'rigineer6g:opinion or;project control.
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CERT. NO. O S Sq ,3 `I g. S� . INSPECTOR NAME JJ J J T lk el 15
DATE I H E V O Z INSPECTOR SIGNATOR
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Page of
DAVE ESTE` `VEINS
Inspectit' onk Services "`
:'PROJECT�t r, A L�'ESr\ASk; 13 :. ,.� .PROJECT. #
ADDRESS' Sy - S`�q B:K 1:4 53 ,_8Eo :6A ' CLIENT
N+L L- PL A iA I; t LSV . I DATE
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ENGINEER .tx (.] S A �`c� _ C. CONTRACTOR,1 EL M AM
INSPECTION TYPE y
INSPECTIONREP.ORT.
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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 approvea-plans'specifications and applicable sections of the building codes. This report covers
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*-Jthe locations of the.work inspected`only and does not constitute{eriginaering opinion'or protect;control.
CERT. NO. INSPECTOR NAME
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DATE C,c� o�y Z INSPECTOR SIGNATUR
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DAVE STEAVENS
: Inspection Services
PROJECT - i.� e`_S'i 5i' 1 `l '. PROJECT # p7 9u,2
ADDRESS'-5 CLIENT PCS QST -OA
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DATE -o -dS F 6
BLDG PERNIIT # ARCIIITECTGO 6,4
ENGINEERDo-y n1 .SAJoi>= =at— CONTRACTOR�L MAa.
INSPECTION TYPE
INSPECTION REPORT
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CERTIFICATION.OF COMPLIANCE To the best of our know[ edge,,all.of.
the reported work;:unless. otherwise noted,
substantially complies with approved plans, specifications and applicable sections of the Wilding codes This report covers
the locations of the work inspected only acid does_not con_ stitute, engineering opirnon;orxproject control:.
CERT. NO. �S5-9`�y �o
INSPECTOR NAME:
DATEo?OO Z Cle )
INSPECTOR SIGNATURIt