0104-224 (BLDG)LICENSED CONTRACTOR DECLARATION
I heriftfirm under penalty of perjury that I am licensed under provisions of
Chapcommencing 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 am exempt from the Contractor's
License Law for the fol lowing, 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 to construct the project (Sec. 7044, Business & Professionals
Code).
O I. 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:
() I have,and will maintain a certificate of consent to self:insure f6r workers'
compensation, as provided for by Section 3700 of the Labor Code, for the'
performance of the work for which this'.permit is issued.
O I have and.will'. maintain workers' compensation insurance, as required by
Section_ 3700 of the -.Labor Code; for the•performance of th6.work.for; which this -
permit is issued. My workers' -compensation insurance.carrier & policy no. are:
Career 'F; Policy. No.
I°.FAL ,r}I: .:.
(This section need not be completed if the permit valuation is for $100:00 oKle'ss).
(') ,I certify 0G. 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 subject to,the
workers' compensation .laws'of California, and agree that if l should become
sublec6b the workers' compenstion 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'crlminal penalties and civil fines up'to $100,000, in
addition to the cost of compensation, damages as,provided for in Lection 3706
of the Labor Code, inferest and.attorney,s fees.
IMPORTANT Application is he made,to the0irector-of Building and Safety
for a •permit subjects to the con_ ditions 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 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.
Signature (Owner/Agent) Date
BUILDI
DATE
JOB SITE
ADDRESS r.i ppp
OWNER
PERMIT #
PERMIT
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Page �of
DAVE STEAVENS .
Inspection Services
PROJECT;,,
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DATE
BLDG. PERMIT #
ARCHITECT C= -ALBA . 7q&j./•17CL1 L0R
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INSPECTION TYPE
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INSPECTION. REPORT `
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CERTIFICATION OF COMPLIANCE:'To the best of our knowledge, all of the reported work; unlessotherwise noted,
substantially complies with approved plans,.specdications 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. o1U
INSPECTOR,NAM
DATE
INSPECTORSIGNA
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InsPecfion 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.INSPECTOR NAME
DATE u L` �ZcJ[� INSPECTOR SIGNATUF!; c)0 -.-? _
PROJECT ( 0-5 r � 44s,
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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.INSPECTOR NAME
DATE u L` �ZcJ[� INSPECTOR SIGNATUF!; c)0 -.-? _
Page I of
a �
DAVE STEAVENS
Inspection Services:
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CERTIFICATION OF COMPLIANCE'..-T6 the best of our knowledge,.allfof 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. d� �g 3 - J V INSPECTOR NAME \ J`A J. S
DATE c;) P —r&A AJ C / INSPECTOR SIGNATUR Cr—�SLit