0104-222 (BLDG)LICENSED -CONTRACTOR DECLARATION
1 hereby affirm under penalty of perjury that I am licensed under provisions of
C%` apter 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).
( ) 1, 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 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 this 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 workerscompensation insurance carrier & policy no. are:
Carrier Policy No.
NAL )*;i;t?,?41gITV r4306217.4A
(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 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 criminal penalties and civil fines up to $100,000, in
addition"to-thie'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 Quints, 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. l 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#'1.:?
DATE VALUATION LOT 0J."222 TRACT
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OWNER
CONTRACTOR/DESIGNER/EN INFERx
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SC)LA14 A REAL M. '� 'CA
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ENGINEER
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INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE To the best'of our:knowlQdge, all'of the reported•wdrk, unless otherwise noted,
substantially complies with approved plans, ppecrf�cations and applicable sections -of the building codes. This report covers
'substantially
locations of the work inspected only and does not constitute engineenng:opinion or proje control:
CERT. K0. 0 S9 3 �/iq INSPECTOR NAME. \
DAT z / �� /lJ �' v2 �fy �• r', INSPECTOR 31GNATU
Page j of
DAVE STEAVENS
Inspeetion Services
1
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INSPECTION TYPE
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CERTIFICATION. OF COMPLIANCE To the"best of our knowledge, all ofthe 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. Uri S9 3 , !� INSPECTOR NAME�CL 1&_
DATE a: T&A JC .a G6 INSPECTORSIGNATOR� 31 .
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CERTIFICATION OF- COMPLIANCE- To the besfof, out knowledge -all of the reported: work'-6riless otherwise noted,.
:3ubstantially corriplies with approved plans; specifications and appllcalle�sections ofthe byldingreport.covers
he locations of the work inspected`only and does hot constitute;engineenng opiniori.or project:control:
CERT. NO. INSPECTOR.NAME. �E .A t%6 S47
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DATA 5J ��j 1502yfl' / INSPECTOR SIGNATUR��.
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Inspection Services
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CERTIFICATION OF COMPLIANCE To the best of our knowledge,fall of the>reported work, sunless otherwise noted,
--substantially.complies with approvedtplans, specifications and applicable sections of building codes: This. report covers
he locations of the work inspectedonlyand does; not constitute' en meenn o imon'or--;pro ect-control
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CERT. NO. is-61 . INSPECTOR NAME` a `�
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,DATE . INSPECTOR"SIGNATU ' ,�