0104-220 (BLDG)LICENSED CONTRACTOR DECLARATION
I Thereby 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 penaltyof 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:
O .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: ,
( ) 1, have and, Will � maintain workers' compensation insurance, as required by
Sectiori' 3700 of the Labor. Code, for the' performance of the work for which this
permit is issued: My workerscompensation' insurance carrier & policy no. are:
Camey Policy No.
t':AI rt �,I��a1THI;.� 1�:slltiai7t,�.
(This section need not be completed if the permit valuation 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 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 ofcompensation, 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 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
BUILDING PERMIT PERMITp
DATE VALUATION LOT 0104-420 TRACT r
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JOB SITE
ADDRESS
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OWNER
CONTRACTOR /DESIGNER
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CITY OF LA OUINTA
FINANCE DEPT
RECEIPT
DATE
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BY
DATE FINALED
INSPECTOR
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DAVE., STEAVENS,
Inspection Services
PROJECI�4t t) ST I> 5E I Y PROJECT # o? va
ADDRESS S i S CLIENT -?(SA . tj:i ___1 �le) 1'
DATE /O .fic t y a ya 1
BLDG. PERMIT # ARCHITECT Q L.A t2t2W tiCL-7-Ls AC
ENGINES :�I L }j ,j A do e Z4- c' CONTRACTOR eG
INSPECTION TYPE
INSPECTION REPORT
CERTIFICATION OF COMPLIANCE; To the best of our kriowledge, all of the.reportedwork, 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.orproject control.
CERT. NO. INSPECTOR NAMEJE
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CERTIFICATION OF COMPLIANCE; To the best of our kriowledge, all of the.reportedwork, 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.orproject control.
CERT. NO. INSPECTOR NAMEJE
SATE / `% d U®/ INSPECTOR SIGN '�.
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Inspection ,Services
PROJECT : L(J S Nii Ste..//� PROJECT #.: oV�/ - O 3
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DATE.raZ 0? 00 l
BLDG. PERMIT # ARCHITECT,
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CERTIFICATION OF COMPLIANCE To -the best of our -knowledge, all of the reported:work, unless otherwise noted,'.
substantially complies wlth.,apprtved plans; specifications and appllcatile sections of :the building:codes.:This report covers
he locations of the work inspected 'only and does not con"stltute_engineenng -opinion or project, control.
CERT NO. 7�� INSPECTOR NAME.J.E'f1
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DATE -25' 102y'p / INSPECTOR I SIGNATUR6�� @ •-+e`
Page Of
DAVErSTEAVEN5 S.
Ing �'eServices
Inspection= S ices,
PROJECT
PROJECT -
ADDRESS, CLIENT
DATE
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BLDG. PERMIT # ARC -HIT
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ENGINEERI'L,-, CONTRACTORh
..INSPECTION TYPE
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CERTIFICATION"OF COMPLIANCE
OMPLIAKE: To , th'e-66st..''o.i.-opi"kn
substantially complies with. approved -.-,plahs,
speq Otkpnt',
-
e, all of tfierep
he locations of the inspected ohry*-And does -not 'iboriitit6te.'7;'I
engineer
CERT. NO.Q5a:a k4 INSPECTOR NAME -
DATE --ru,
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ted work, un'less otherwise,.noted,
of-thi
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in or., project control.
PROJECT�flvJ�s�
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BLDG. PERMIT '#
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DATE
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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; specifications and applicable sections of:the building codes: This reportcovers
•:the locations of the work inspected`only and does'notconstltute engineering opinion' or project control.
CERT. NO. 0G !:Q ' 44'B " !r -c) INSPECTOR NA' E4E 'Lie
/ (Print Cleary)
DATE ! 3 -�� �% o� U:(�:.) INSPECTOR $IGNATUI 7
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