0104-226 (BLDG)LICENSED CONTRACTOR'DECLARATION
U� I h,erqftirm,.under penalty ofperjury that loam licensed under provisions of
Chap(commencing with Section 7000) of Division 3 of the Business and
C14UJ Professionals Code,•arid my License is in full force and effect.
<� License # Lic. Class Exp. -Date
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O Date Signature of Contractor
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~OWNER -BUILDER DECLARATION
Ha I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 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 to construct the project: (Sec. 7044, Business & 'Professionals
Code).
c?)O I am exemptrunder Secti
U-) on _ . ,. B&P:C. for this reason
N Date Signature of Owner
a Q WORKER'S COMPENSATION DECLARATION
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O , I. hereby affirm• under penalty of. perjury :one' bf, the following declarations:
�,. p (') I have and will.maintain a certificate of consent to self -,insure for workers'
X w UL compensation,:.as: provided for by Section 3700 of the LaborlCode, for the
-m _ -J periormance.bf the work for which this permit is issued.
Q () ( ) ;I,Ahave and'wlil maintain workers' compensation Insurance }as required by
p 0 Q Section 3700 of the Labor, Code' for the performance of the works for which this
tl CIN— permlt`is issued..My'workers compensation insurance carrier &.policy no. are: -
Z At:Carrier Policy No.
CA), 1tp1.'kW'.0.1l"Y,-
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This section need,not be completed if the permit valuation is for $100:00 or less).
( ) ,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 sub'ect.to the
workers' compensation. laws -of California,° and agree that if I should become
¢ Subject to the w&kerscompensation provisions of Section 3700 of the Labor
Code, I shall jorthwith comply withlthose provisions.
Date: Applicant
`. { i
Warnin _Failure to,secure Workers'.Com ensation cuvera a is unlawful. and
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shall subject an employer to, criminal penalties and civil fine§u p to'$100,000, in
addition to the'costof compensation, damages as provided for in Section 3706
of the:Labor Code Interest and attorneys fees.
IMPORTANT -Application is hereby'm6dd10 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.
, U___7
.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 lawsrelating 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
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BUILDING -PERMIT
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PERMIT"
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ADDRESS
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USE OF PERMIT
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APR 2 0 2001 '..f i
CITY OF LA OUINTA
DATE FINALED INSPECTOR
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DA NUSTEAVENS.-
inp , dioA. Services'
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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, or project control:
�CERT. NO. ��3 �•.� ' y INSPECTORNAME
)DATE 13 -Ile INSPECTOR'SIGNATU
PROJECT #
CLIENTGA uj i5 Hp 4
DATE- . 3u���( oZy� r
ARCHITECT I!�A R >Qfe w r T src:T u r2
CONTRACTORIEG:, f.4A ra . c i Fr 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 aridapplicable sections,of the -building codes. This report covers
the locations of the work inspected only and does not constitute engineenng:opinion or project control
CERT. ISO. OSI 7 INSPECTOR NAME 1 _-:.:.. �t ✓ . J
`O,,ATE 'I ✓ K C_Y NSPECTOR SIG' IE