0108-334 (BLDG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
-Chlapter 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
oV.i 1. i, 4
Date _ Signature of Contractor
OWNER-BUILDERDECLARATION
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 the property;�or- my,employees with wages as their sole
compensation, will.do'th.e work, and the. structure is not intended or offered for
sale (Sec. 7044, Business;& Professionals Code).
( ) 1, as owner of the property, ani exclusively contracting with.licensed
contractors to construct` the project ;(Sec: 7044, Business & Professionals
Code);: . ,
( .} I am exempt under.Section URC; for this reason
Date"'" Signature' of Owner
WORKER'S' COMPENSATION,DECL"ARATION
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 Labor Code, .for the
`performance of the work`for which'this permit Is issued
( ). I have and,will maintain:workers"compensation Insurance; as required by...,
Section`3700.6f the -Labor Code;,: for:the. performance of'the work for which'this
permit .is_ Issued. 'My workers' ;compensation insurance carrier & policy. no. are:
LamPolicyNo.
1.15tJ,ai'r �
(This section:need not be completed if the permit valuation is for $100.00 or less).
O I certify that in the perforniance of`the, work for which this,permit is issued,
I shall. not 'employ -any person in any, manner so'as to become subject to the
workers' compensation laws' of:Cal ifornia;' and'agree that if.) should become
subject to'the•workers' 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 and
•shall subject:an employer`to criminal penalties and,civil fines up to $100,000, in
addition..:to fie -cost of -compensation, damages as provided for in,Section 3706
of the1abor Code 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.
Rinnatrlry fownar/Anent) __
Date
PERMIT #
BUILDING PERMIT
DATE VALUATION LOT Ci i Ct18 1r{ TRACT
JOB SITE
APN
ADDRESS
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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
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DAVE STEAVENS
Inspection Serrvices
BLDG. PERMIT #
::`ENGINEER :�•�.� � SR
INSPECTION TYPE,
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CLIENT ,. �G At
DATE
ARCE9TECT. C..,OLO +4 44 acN t'TE_C (
CONTRACTOR �b EL .,YVI AR. � Amt c C_ .
INSPECTION.REPORT
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�w CERTIEICATION'OF COMPLIANCE To th'e best of our knowledge, all of the reported work -unless otherwise noted
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substantially complies w)th,#pproved plans, specifications and,`appbcable sections of;tht3: building codes. This report covers
the locations of the work inspected only and does,not co'nst)tute•eng neering opinion or project control
CERT NO. ag5g.3y8'. 50' i INSPECTOR NAME ( AJ r. S /,.EA IIEU
'.� . DATE /' C; ' . U O Z INSPECTOR SIGNATOR' ✓ y .'��,
DAVE STEAVENS
Page k of J,+
Inspection Services
PROJECT ?W A S C (C3 PROJECT # col t» Z
ADDRESS Sy - G; 37. ^e. ZS I
0444 ILL BL
BLDG. PERMIT #
CLIENT PyA (A) e5f Wo A
DATE A-50 FCS .2002–
ARCHITECT
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ENGINEER �uAa
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CONTRACTOR Ct^
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,
J -0
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 or project control.
CERT. NO.
DATE d� /4'�'� al) d Z
INSPECTOR NAME _ t l A ✓ �/ �-� ��u g
.. (P int_C eacly)��
INSPECTOR SIGNATURE
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Page of
DAVE, STEAVENS
`.., Inspection., services ,
PROJECT A U�N E-57 C, 13 PROJECT # C o a - 0 3
ADDRESS54CLIENT.�� '�JESi Kofi
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BLDG.. -PERMIT # :.-ARCHITECT . 0,�3 AA Q cw r r E c:r� , z t
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'INSPECTION TYPE
INSPECTION REPORT
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%,tCERTIFICATION OF COMPLIANCE 'To the best of our knowledge, all of the reported work;.unless otherwise noted,
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bstantially complies with'approved plans; specifications and applicable sections of the building codes. This report covers
locations of the work inspected only and s notconsdoetitute;engineering opmion.or project, control.
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CERT. NO. INSPECTOR NAME' }�'� ' A�tL'
DATE Z ,INSPECTOR SIGNATURL :>'
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CERTIFICATION OF COMPLIANCE To the best,of our knowledge, all..of the reported work; unless otherwise noted,
substantially complies wnn, approved plans; specifications and applicable sections of. the building codes. This report covers
-Jthe locations of the work inspected: only and does not constitute }englneeririg:iiplrnon>or project control.
CERT.NO. O'SS9'3y:g� Sa 1NSPECTORNAME JJ� Jam' Y\JEil�
DATE %' E 13 oZ' Ci O Z :' ,
INSPECTOR SIGNATUR [� n p e�