0104-221 (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
Profes0onals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
7'111 T ;12 it (11313 1 2(.
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 isnot 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 I am exempt under Section = P.C.B&for.this re on
Date Signature of Owner
WORKER'S COMPENSATION' DECLARATION
I hereby affirm under penalty of- perjury one of the. following declarations:
O I have "and'will maintain a certificate of consent10" 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.
Iave and will .maintain workers' compensation insurance; as required by
Section 3700 of: the Labors Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy'no. are:
Gainer Policy No.
-:1'Ll.i fi'.lf i.l:. h.�t'rT•f, 1�r.. .- :�:(;Sjt{,%l'.%At) '
(This section need not be completed if the permitvaluation is for $100.00 or less).
O 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.worke�s' compensation provisions of Section 3700 of the Labor -
Code, !',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, indemnify
& 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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CITY OF LA OUINTA
FINANCE DEPT
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR'
Page �_ of
DAVE STEAVENS
Inspection:- Services
PROJECT„.. A� FT�,s (°-A PROJECT #
ADDRESS 1Sr CLIENT��
DATE
BLDG. PERMIT, # ARCHITECT 66'`3p,
ENGINEER _\ ,`,
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INSPECTION TYPE
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CERTIFICATION OF COMPLIANCE PTo the bestof our knowledge, alf•of the reported work,.unless otherwise noted;:
Dubstantially complies with approved plans; specifications and;app ! able sections of:`the; building :codes: This report covers
he locations of the work`insp"ectedonIy and does not consbtute;engineenng opinion oT: project'Control.
CERT. NO. 059::4�3'4� - �O INSPECTOR
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DATE . 7" . JTZ I INSPECTOR SIGNATURES..r
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Of
Page
DAVE STE'A.,��,:ENS
Inspection'Services '
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PROJECT 47C- PROJECT #
ADDRESS : ' CLIENTS
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BLDG. PERAUT' # ARCHITECT GoLj�# :-Aizcea , TLc--r 4, le ,
ENGINEER. +�.� -i � SCJ o,'c . � ` CONTRACTOREC, r►1 fo �2 ,A c i Fr c:
INSPECTION TYPE
INSPECTION REPORT
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CERTIFICATION_ OF COMPLIANCE To the bestof our.knowledge, all'of the'reported work,,,.unles§.otherwise noted,
substantially complies with-approyedplans; specifications ar d;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: (3 z7 ' sy" " INSPECTOR NAM �" J ZA 06 5,
` DATE INSPECTOR SIGNATOR Yom'
Page of Z
DAVE STEAVENS
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CERTIFICATION OFCOMPLIANCE To the 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 c6hst�tute engineering opinion or project coritrol.
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CERT. NO. Og .5 3 f 9 -S'0 INSPECTOR NAME •J E v/ es°IJe:J.S'
DATE S� 1� INSPECTOR SIGNATUR��` Q,..^