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0104-224 (BLDG)LICENSED CONTRACTOWDECLARATION. I herqftirm under penalty of perjurj/_that I am licensed under provisions of Chap(commencing with Section 7000) of Division 3 of the Business and Profesionals Code, and my License is in full force and effect. License # Lic. Class Exp. Date 31 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: as. owner of the property, or my.employees with wages as their sole Compensation, will do the'work, and the structure isnot intended or offered for sale (Sec.7 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). O I am exempt under Section + B&P.C. for this reason - Date rSignature oY Owner WORKER'S COMPENSATION DECLARATION _ I hereby affirm. under penalty of -perjury one of the following declarations: Piaveand 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 which4his permit is issued. ( ) '1,have and:wlll maintain ,woi�kers' compensation insurance, as required by., Section 3700 of ahe Labor: Code for the performance of thework for which this permit; is -issued: My workers compensation ,insurance rcarrier & policy 'no., are: Carrier s Policy No. (This sectionneednot be completed if the permit valuation is for $100.00 or•less). ( ) lcertify that in the performance of.thew orkfor 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 I should become Subject to the in6rkers' compensation provisions 'of, Section 3700 of the'L`abor Code;:l stiall 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 $100 000, in addition to.the;; cosf;of`compensation,'damages as.provided for in Pection 3706. of the Labor Code,'interest andattorriey's fees:.. IMPORTANT Application is hereby made to the Director of Building and Safety . for a permit' subject.-Ao the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this applicationis made & each person at whose request, and for whose benefit work is performed under or,pursuant to any permit issued as a result of this appljcaton agrees to, & shall, indemnify & hold harmless the City of La Ouinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree, to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes. Signature (Owner/Agent) Date BUILDING PERMIT PERMIT” • O. DATE VALUATION LOT 0.1041-12d3 TRACT JOB SITE APN ADDRESS - OWNER CONTRACTOR / DESIGNER / EN 1NEER 'KAU,.'NGUZ'f.1AC.1FK.!0iHf:RALCOM—RACTO 41,57 `TPRV,14110 AVE?. 11302 C'A 92VP lel" 9205 (846)792.-1.500 Ck i* '5821 USE OF PERMIT,.. 1lrVORMA'f oN :FR.t`3(..'•).�:T.:I:,� Q:T':c-t::t?..T:? lh 16C�.S'f. CHAR.).XS P1, FA •: Jtd, .wi l�¢f! <I J J fi 54-1611 OAK MIKE-. •• 11,01U)IN10yd<iTY.PNr II 'V 01 . N'f;ht't° B'!'f?t.f;"r'f.:riAL AS;'f'rt.SaiC'/t1'i 3ti;±+ ?0 ' y . 1r'!'l.ie'i? ���!•Tt�!ff aixl�tifJ,ti41 f:e`') ,J • (:`()f.(' ()" •t''t+,1d h.,�1:a°f ` A':49: i�`. �'tl }J�:�JI�,:1;;' . - (-000, erT ?' _000 i.f4`�;t7C1 ;� I l'.C:ri�eft F.rf iti7FC►:+1 }�'tef�• . i2.E;;�lf? i it l • <<C i)•l",$ T ••t){3r)-�:2.ffu n;� +f �- f �j� fh>!:.• r'i " `.i Tc::"j`iCik! t f►a 'Nji.,F,TI d_`t'IL r:`�c. $200.00 D310.00 i ) UP: T'(O S;EOk►a�) APR 2 0 2.001 CITY OF LA OUINTA FINANCE DEPT R BY DATE FINALED INSPECTOR "R"r•sk�tX`} _-^i�"3'� t,F`!••: �a - 'a•��''.- �rF o'1,^ � �. riY ams �1 �7`ti'��k k'�y'?.'��".�Tt?, uivl �� r�r r.J. L'�. aWs t6w rYa�? .. f Page: (: 0f DAVE. STEAVENS Inspection Services PROJECT` A� V�iE Nr15E I- �4 PROJECT-4,c?'va J D 'ADDRESS LIt .ftri ` .CLIENT: 09_C'7 o�lyfi z DATE BLD.G! PERMIT # ARCHITECT C- OLRA , : A&_Jl.T cT c;►�2G ENGINEE(JL. CONTRACTOR L MAR r�i4ciFl� INSPECTION TYPE•. INSPECTION REPORT :�L�N� ' tAT"i' 1 CSS -� SNEA tom\ Ra �` � \,1� ti�� �Lt�[.�:[ r�i�Ai t;�L��'�,.►� � �'.i O Y 1 I' �: J' 440 t SZ r SCS ?AK 79ttr, 1tT Alc S [:•meq. -q F�:i-1 A,.]� [77: J. lea ]v .t ,7 we CERTIFICATION Of=.COMPLIANCE To the bestof ourknowledge, all of the reported work, unless otherwise noted, --� substantially complies with approved plans, specifications andapplicable sections of the building codes. This report covers ,the locations.of the work inspected only and does not consUtufe;engmeenng opinion or protect control y CERT NO. 3 INSPECTOR NAM -DATE � •- �{ :.,�%fr f.,�T4 x _ 4k 4 s £ r• INSPECTOR SIGNA '_ ro -- Page ( of DAVE STEAVENS , Inspec�;t dw ervices ,< I PROJECT R wcs --, 'I �i t}5Et (:!A PROJECT # . 01 c I ADDRESS Sy -11.4 1 '1 0. l R.� CLIEN:T _ - Q aD DAFCT9-tE , DATE:.. BLDG..PERMIT # ARCHITECT (a'OLZA, APCP+ Ire r, 1Z ' ENGINEER CONTRACTOR j:L 'M A ,2 AC- i r- �C INSPECTION TYPEra�� INSPECTION REPORT ` n _ , � E a -t MA s — a�.LOC-s � d � 1 � ' t C � A o� s- I'1 -tet= �, -k jQ7TO IR4a2 (.,) � LvcS N©� 5 1 1� P�v-1 �y �`�iA 1ZoAS- j�' C:��.JG� W is ,oto ,r '` k c:c:- Ny�CS 1 i:6?�1^1'3% ]��A ps k ZIA, OA4CT2�E t 1,4 vc �uctS 11�A b�yt75- (-1 tau.l<oTr-I �� �> ►A ' Yr ._ 1µT .• 1 CERTIFICATION OF COMPLIANCE To the best of our knowledge, all.:of the reported work, unless otherwise noted, substantially complies with approved plans; specifications and :appllcati1 sections of: the building codes. This report' covers ', n . .. the locations of the work inspected onlykand does not,constitutp:engineering�opinion or project control CER C .NO.Uf� INSPECTOR NAME �'J:teA.J'� i Clea,fy� DATE INSPECTOR SIGNATOR,