0104-221 (BLDG)LICENSED CONTRACTOR DECLARATION
I F13reby 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
73 4152, :Fl 038 IM
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).
( ) 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.
tti) 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.
CA), 1;,NL'&M14ffY W3062 04A
(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,
1• 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 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 Quints, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and .void if
work Isnot commenced within 180 days from date of issuance of such
permit,, -6r 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"
DATEVALUATION LOT 0104.221 TRACT
JOB SITE
ADDRESS
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OA OCCRA~R:T�.
OWNER
CONTRACTOR / DESIGNER / EN INFERa'`41
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462 MVEM AVF_ #302
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i�?LANA BEACH C"A ' 9
(858)792w1500
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USE OF PERMIT
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CITY OF LA OUINTA
FINANCE DEPT;:
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RECEIPT
DATE
BY
DATE FINALEDINSPECTOR
+' Page Z.. of Z
_ '. •DAVE* ST:EAVE•NS
Inspection- .Services
PROJEC�A PROJECT # o7cs0/03
`ADDRESS P►S t_�—� n CLIENT' Tt .(,cJ E.5T f/oA
DATE ,2:5" _j"cPiJ 6 o? o+o l
BLDG. PERMIT # ARCH_ ITECT
ENGINEER 0 sJ� J o:i.E. Sy L CONTRACTOAAC`l MAA PAc>r / c_
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INSPECTION. TYPE
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-INSPECTION REPORT,•
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CERTIFICATION. OF COMPLIANCE To the best ofour.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''engineering opinion or project control
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.CERT:.NO. Oi'S_��f�'7%-�0 INSPECTOR NAME �I JE .A1Iej::S
• DATE � 5� .7� � � : •• . . • : • �, , , f ; \ ', > = - �:I
01 uU / . - INSPECTOR SIGNATUR
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Page of
DAVE STEAVENS
_ Inspection..Se wice
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PROJECTh
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PROJECT #
ADDRESS CLIENT '(-A
DATE (q Sit,J �. o2c3o
BLDG. PERMIT # ARCHITECT�a�ad�,z�„�
ENGINEER,�L, `� �,,;,z I i, r•cY CONTRACTOR,
INSPECTION TYPE
INSPECTION REPORT .
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CERTIFICATION OF COMPLIANCE To:the best of our.knowledge, all,: of the reported work;: unlessotherwise noted;
ubstantially complies with approved plans; specifications and applicable sections of>the 6uldingcodes.rhis report covers
he locations of the work inspected only and does�not'constitute`erigineermg"opirnori*or:project control.
CERT. NO. Qr�q�3 g - �j 0 INSPECTOR NAME I } J L ,
DATE . .,1 Up INSPECTOR SIGNATURE ,✓ _
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Page of .:,.
r DAVE STEAD , ENSI.
Inspection Services
~PROJECT GA Q c% -r -&H A se , k A y ' PROJECT #,;. 0 3
ADDRESS CLI -ENT C, A ti1�S i Ho A
DATE �' j F �Tk ►J E "eLoo I
BLDG. PERMIT # ARCHITECT�0L JNr2Cb4 i Tt.LT 4 oeL
ENGINEER %J'%.A CONTRACTOR : rh A z ;)a _ r Fi C_
INSPECTION TYPE
INSPEC°TION REPORT
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CERTIFICATION OF COMPLIANCE To the best of our knowledge, all; of the reported work,,unlessotherwise•noted,
substantially complies with approveii plans, specifications and applicable sections of;"the building codes: This report:covers
.the locations of the.woek inspected only�and does not consfitute:engirieenng opinion -or project control.:
CERT. NO. f 3 8 - s� INSPECTOR "ME." _ '. �1� d1L I
a �%� INSPECTO
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