0104-222 (BLDG)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
-7.'
.a'i f2 fi3/'s jl
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjurythat Tam 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) . r.
O 'I am 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. for workers'
compensation, as provided 'for by Section .3700,6 f the Labor Code, -for the
performance of the work for which this�permitis.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` corripensatid6'insurance carrier &'policy -no. are
Caitier Y Policy No:
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(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 forffiwith'comply witKthose 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, compens ation, damages as -provided for in Section:3706
of the'Labor Codei interest and attorney's fees.
IMPORTANT,Application is -hereby- made, the Director of Building and Safety
for a • permit_; subject. -to 'theconditions 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
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USE OF PERMIT
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DAVE _:STEAVENS
Inspection: Services
rPROJ1 PROJECT
ADDRESS' AS' L 7, r- CLIENT �A u� S t=FoA
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- DATE' I.
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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; specrficatlons and apli
pcable sections of the building codes. This reportcovers
�he locations of the work inspected:only and does not con-stdute engineering opinion or project control.
CERT. X10. -INSPECTOR NAME \'iq'LIt ►JS . .
DATE ..[ ! . ��'. 02 csU ' (. INSPECTOR SIGNATU. ..
of.
Page .
...DA VEL.•STEAVENS : i
Inspection Services r
PROJECT PROJECT•I
ADDRESS L� ST S CLIENT 'h)t too 0�
DATE
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`ENGINEER - �og L CONTRACTOR hEL
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CERTIFICATION OF COMPLIANCE: To the,best of our knowledge, all of the reported work, unless otherwise noted,
.-substantially complies witWapproved plahs,-specifications and applicable sections of the building codes. This report covers
.__)he locations of the work inspected: only and does not constitute engineering opinion or project control.-
CERT.
ontrol.CERT. NO. S• -+�� .� 7 - S'd ' '-:'1 INSPECTOR NAME. J c �`f' A V Cl -J S
DATE`f:�,g lIL rJ t_ INSPECTOR SIGNATUR _l.]
Page .2. of Z
DAVE: STEAVENS:
Inspection :Seiviees '
PROJEC'14��Uit'sill &W '/.f4 PROJECT C X66/
ADDRESS 14`55 S L% S'i n CLIENT S i
DATE
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BLDG. PERMIT # ARCHITECT o - � erd .I T' Z c-rc� 2 t..
ENGINEER �J i J J o t Sid C. :. CONTRACTORS C . MA r2 1ci� i-c j
INSPECTION .TYPE
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE To the be of our knowledge, alG:of the';reported,work; unless othervvise noted,
:�fubstantially complies with approved plans; specifications and applicable sections of the building.. codes. This report covers
he locations of the work inspectedionly and ddes:not constitute';engineenng opinion or project control:
CERT.NO.INSPECTORNAME JE . f1
02O / INSPECTOR SIGNATUR�� __
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Page of
AVEFSTEAVEN
Inspection Services
PROJECT�C�A �.1 ST I! A �i PROJECT # o�2
ADDRESS CLIENT. k_.O f -ST t -'f o Ar
DATE. A:1 Jam►.
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ENGINEERJ,..0 o rJ .ajn, i-:' ' I rJ c- CONTRACTORjf_i ; aM A R
INSPECTION TYPE
1
INSPECTIONS aREPORT
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CERTIFICATION OF COMPLIANCE To the best of our knowledge, all of the reported work,tunless:otherwise noted {
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--substantially complies with approved`plans; specrfications and applicable sections of the buildingcodes. This report -covers
, Jhe locations of the work inspec gorily aril does not corist�tute engineering opinion or project.Control.
CERT. NO. P�9S9 3� C� INSPECTOR NAME z
7.
DATE PECTORSIGNATU