0104-223 (BLDG)LICENSED CONTRACTOR`DECLARATION
Khereby 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
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:
( ) 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 .j am exempt under,Sectiorr 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 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 which thls.permit`is issued.
" (') I 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:
Carrier = ' Policy No.
i.:A1 1 rf E', !,T i :f' "Y, P;462
(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 subject to the
workers' compensation! laws. of California, -and agree that if I should become
subject' -to the workers' compensation provisions of Section 3700 of thelabor,
,Code,,l shall 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 cost of compensation, damages as provided for in Section 3706 . .
of the Labor Code, 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, indemnity
& 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"
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DATE VALUATION LOT 09104.22.3 TRACT
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011 OF LA QUIN1A
FINANCE- DIV
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
Page Z of Z
PROJECT #..
.CLIENT ;�A 5-7 Nu A
DATE
ARCHITECT�—
CONTRACTOR C -L m q r2 y7A C t Fi C
INSPECTION REPORT
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j\.e- i -AI s 1.3 I �S -� - ! L JG►.�� U 1. _
CERTIFICATION OF COMPLIANCE:.TJDA a best of our knowledge; all of -the reported work;. unlesi otherwise noted,
-"--,,substantially complies with approved plans, sp'eoications 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. 19�93 UES ' Sv INSPECTOR.NAME �V'L)
V.DA`E 3 -;:ZU•L,! ,;7_cXq INSPECTORS1GNATUMEt2_Q s"
- Page of. I
.DAVE''STEA X N N.
Inco on� Services r
1
PROJECT.. tx�r.S�Pi` PROJECT:
ADDRESS L� ST .� CLIENT... 6:g
DATE 01'a cU 1.
BLDG: PERMIT # . ARCHITECT rdLt3i�.rzcN/TEc_�uRr'.
tENGINEERtn..0 NA SIS) ti, E 'Ti: L CONTRACTOR'bEC M A 2 PAC Fl C
-INSPECTION TYPE
`',
INSPECTIONS REPORT'-
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CERTIFICATION OF COMPLIANCE To ttie,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
,—)he locations of the'work inspected only-and does: •not:constitute`engineenng opinion or project control.
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CERT N.O. QPM `� ,9' .� 7 � Sd . � `
INSPECTOR NAME J;Z. tQjQ ENS .
DAi �g` S� rJ t_y.� (' INSPECTOR SIGNATURE
Page �_ of
DAVE. STEAVENS
Inspection=, Services
PROJEt-&-A. (,J�s`� ��-1 Sk: =�li " PROJECT #.. 9'6-ta ! O 3
ADDRESS CLIENT�1
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BLDG. PERMIT # .: ARCIIITEGT'C=;,0L 2ctA �-rt ura
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CONTRACTORNLL.., yin Z_ F
INSPECTION TYPE
INSPECTION. -REPORT
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CERTIFICATION; OF COMPLIANCE To -the best;,of our knowledge,wall;of the reported work;.. unless otherwise. noted; I
.,substantially complies' with approved plans, specifications and epplicclole sections of the building"codes..This report covers M.
._)he locations of the work inspected:only arid"does hotsconstitute engineering opinion or projecizontrol.
CERT, NO. O �_�3 '�d -INSPECTOR NAME !JE I
D;►FE S J CCN p�C�D I , INSPECTOR SIGNAT. " RE