0104-226 (BLDG)LICENSED CONTRACTOR DECLARATION
I her Irm under penalty of perjury that I am licensed under provisions of
Chap(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
7i,315 7 b
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 the 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 toconstruct the project (Sec. 7044, Business & Professionals
Code):
() I.am exempt under Section B&RC. for this reason
Date Signature of Owner
WORKER'S 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 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 of the Labor Code, for the performance of the work for which this
permit is'issued. My workers' compensation .insurance carrier & policy no. are:
Carrier . { Policy No. :..
.(This section.need not be -completed if the permit .valuation is for $1,00.00'or less).
() I certify that in the performance of the work for which this,peemit is issued,
I shalt not employ any person in any manner so as to become sUbject to the
workers' compensationlaws of California, .and agree .that if I should become
subject to the workers''_compensation provisions of Section 3700 of the Labor
Code; f shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation cuveraage is unlawful and
shall subject an.employer to criminal,.penalties and civil finesup to,$100,006,46
addition to ihe'cost of compensation; damages'as provided for in Section 3706
of the Labor Code, interest andattorney'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 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 1$0 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.
Signature (Owner/Agent) Date
BUILDING* PERMIT PERMITp
•
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DATE VALUATION LOT OVA -226 TRACT
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JOB SITE
APN
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ADDRESS A 77 �� t
r�AK IRFIX
—
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OWNER
CONTRACTOR/DESIGNER/EN (NEER
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LA Q7).bl'l.:A CA 92.253
'801-.dKA BEACH H CA 92075..:
(s5sp92.13001:3$23
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USE OF PERMIT
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$209.00
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$2,09.00
CITY OF LA OUINTA
i
IRECELET
BY
DATE FINALED
INSPECTOR
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CERTIFICATION OF COMPLIANCE: To -the. best of ou.r knowledge; all of the reported work, unless otherwise noted,
substantially 'complies with approved plans,'specif)cations andapplicable 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. N0. �� : ^ .5 U iNSPECTOR'NAME
• `, - _ (Pri CI arly)
DATE . I 3 INSPECTOR SIGNATURE �J C1A-
j"-^(' ""v�-�I.n.r �+Y'-�j'-', *v i';��•"��"^,`. ,"'"'�. 'S�'«•'Y�'`��n••-••.'"lrs..-.;i.--...... r„r... ._.ti�.r....s -ti,.
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,.AVESTEAVENt
Inspection Services
PROJECTT�A cJi 5 i N s— 1 F\ PROJECT # c?CrO I U 3
ADDRESS . ' CLIENTC�AS f-�O 4
DATE-. 3 ZLX_t_*,( 0-U0 f
BLDG. PERMIT # . ARCHITECT s��A A Age-" rr�Tug. 6
ENGINEERl•., , JAS 1 c� 6 �: :� c CONTRACTOR L mA ra c, fri e,
INSPECTION TYPE' y.
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 approve d,plans,-specifications and applicable sections of the. building codes. This report covers
''Ithe locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. NO. � 7 . ` '� S C� I INSPECTOR NAME ✓e ^).5
+� �� (Print Cl'1e cry)
DATE 3 JK L -Y .� I INSPECTOR SIGNATURE (�\ ( , , n r�1Cf