0104-223 (MISC)LICENSED CONTRACTOR DECLARATION
I. hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (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
1331:5; :Fa 43d'>3
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:
( ) 1, 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).
( ) I 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.:
( ) I have and will.maintairi 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. -,
O 'f 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:
Carver Policy No.
t: AI.,l t !L?Rit.01 x F "s'A.
(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,
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 shouldbecome
subject to the workers' compensation provisions of Section' .3700 of the Labor
Code, I-shallforthwith comply with those provisions.
Date: Applicant
Warning: Failureto 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 cost of compensation; damages as provided for in Section 3706
of the Labor Code, interest, and attorneys 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 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 PERMITp
DATE VALUATION LOT 0104-2 :3 TRACT • !i ; r.
JOB SITE
APN fes;•
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN INEER
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USE OF PERMIT
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CITY OF LA QUINIA
FINANCE. DEPT
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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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,.specications and applicable sections ofahe-building codes. This report covers
—)he locations of the work inspected only and does*not constitute engineering opinion or project control.
CERT. NO. Q7 3 �%� , s�'�-' INSPECTOR NAME �: i J =:'.
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Y- : DATE 3 -:Tu L`, .Zero j INSPECTOR SIGNATU •� t �• ' .. .
a . Page of i
DAVET-E
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INSPECTION"REPORT
CERTIFICATION OF COMPLIANCE To the best; of our•khowledgi
�,su6stantially complies wifh.approved plans, specifications and apE
✓he locations of the work inspected only.and does not constitute ei
CERT. NO. 5 .3.778 ' SU' INSPECTOF
DATE 12: c�cxeI. .: .
,INSPECTOR
otherwise noted,
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CERTIFICATION OF COMPLIANCE To the best; of our•khowledgi
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✓he locations of the work inspected only.and does not constitute ei
CERT. NO. 5 .3.778 ' SU' INSPECTOF
DATE 12: c�cxeI. .: .
,INSPECTOR
otherwise noted,
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge,* all of the reported worik,' unless otherwise noted,
.--,substantially complies with approved plans, specifications and applicable rt csections of the building codes. This repoovers
_—)he locations of the work inspected oql 'and does'not'con"stitute engineering opinion or project control:.
CERT NO. 7� ." �d : > INSPECTOR NAME.''` �J ' "t A vcij S
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DATE � g �L rJ t. INSPECTOR SIGNATUR
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Inspection Services,
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ADDRESS CLIENT? �P1 uJ'E,ST \-�OP%
DATE ;L- C?0 I.
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ENGINEERk CONTRACTOR��.>,.
INSPECTION TYPE
INSPECTION REPORT
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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. Y,
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DATE ffZeA/C 49700I INSPECTOR SIGNATURE T