0104-225 (BLDG)' LICENSED N ^ � ^ . ^ ! ,. ^ -� � � — •' � —
CO TRACTOR DECLARATION
I_t; lr Irm-under-penalty-of perjury-that-I-am-licensed,.underprovisions 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
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of'perjury that I amexempt 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).
( ) .1, as owner, of. the property, am exclusively contracting with licensed
contractors to construct the project (Sec.' 7044, .Business & Professionals
Code).. R
0 1 am exempt under Section 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:
O I have and w111 a
maintain 'certificate of consent to self-insure.4or workers'
compensation; as provided for''tiy Section 3701) of the Labor Code, for,the
performance of the work for which:this permit Is Issued. ;
( ) I have and,wllf maintain worker's' compensation. Insurance as required by
Section 3700 of -the Labor Code„for the performance of the;work for•:which this ..
permitiso Issued: 'My' workers' compensation insurance carrier. policy no. are:
Carrier' Policy No.
(This sectlo,n need not•be•completed if the peimit valuation is for $100.00 or less).
O I certify, that in theperformance-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`-compensaiion laws of California, -and agree that if 1: sh6uld:become
Subject "toAhe "workers' compensation provisions of Section_ 3700 of..the Labor
Code,' lshall forthwith comply with those provisions.
Date: % Applicant's
Warning: Failure to secure Workers Compensation coverage is unlawful and
shall subject an employer to cnminal penalties and:civil fines up to $100 000, in
addition -to the cost of compensation, damagesas provided for in Section 3706
'o'd
of the Labor Ce, 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 isnot commenced within 180 days from date of issuance of such
permit, or cessation of work for 1130 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 PERMIT -q_
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CERTIFICATION OF COMPLIANCE To the best'of our:knowledge, alEof the reported work, unless`. otherwise noted,
substantially complies with approved plans specrfications and 'applicable §ectionsof the.building codes: This report covers
J'he locations of the'work.inspected only and does not constitute' engineenng,opinion or project control:
CERT.R0. S 7 .3 'fg SSD ci INSPECTOR NAM J �- ".
DATE INSPECTOR SIGNATU '+
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CERTIFICATION OF COMPLIANCE Tathe best of our knowledge, -.aII bf-the.reported work, unless btherWis'e noted,
substantially complies with apprqved p4gs, specifications and appli6able sections of:the building codes. This report covers
the locations.of thevork- inspected only-,and,d6es not constitute engineering gpinion.or projectcontrol.
CERT NO.
.,INSPECTOR NAME.31, A C
INSPECTORSIdkATU
DATE Z7,k L Y e
INSPECTION."REPORT
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CERTIFICATION OF COMPLIANCE To the best of our knowledge, all of the'reported work,:unless otherwise noted,
substantially corrtplies with,approved plans, specificatigns and applicable sections.of the;building. codes -:This report covers
the locations of thework inspected only and does not constitute engineenn6,0 monor-project control.
CERT. NO.:INSPECTOR NAME AJG� S
j,
DATE pi .1 1� b? ua / J. r' INSPECTOR SIGNATU
Page I of �--
DA.VE :STEAENS
-
'Inspection Services
PROJECTt�- C -,A . t� �.S:i
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INSPECTION."REPORT
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CERTIFICATION OF COMPLIANCE To the best of our knowledge, all of the'reported work,:unless otherwise noted,
substantially corrtplies with,approved plans, specificatigns and applicable sections.of the;building. codes -:This report covers
the locations of thework inspected only and does not constitute engineenn6,0 monor-project control.
CERT. NO.:INSPECTOR NAME AJG� S
j,
DATE pi .1 1� b? ua / J. r' INSPECTOR SIGNATU