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0104-220 (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 711 "t 5 2. i1 Date Signature of Contractor 03131/21( 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 perforrriance "of the work for which this permit is issued. (') I. -have and.. will = maintain' workers' .compensation' 'insurance; as required by Section 3700 of•'he Labor Code_foi'the performance of the work for which this permit is issued. My workers' compensation insurance carrier & policy no. are: Carrier Policy No. (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 shalfforthwith comply with those provisions. Date:, A Applicant 4 Warning: Failure to secure Workers' Compensation coverage is unlawful'and shall subject amemployer 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 andZafety 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 PERMIT# :. .• DATE VALUATION LOT 0104420 TRACT JOB SITE ADDRESS APN 21 0Alt J."Krf. _ _Np OWNER CONTRACTOR/DESIGNER / EN ,NEER ya. POAV;l.E e>x !<:Ei� .i i':+1.+.''t�'i:IJ�,I �zis(:t{+f. l`C�,�3'F Diil.,J[vlAR PAMFIC.". GF9KIdALC ONT'RAC110 J'=i' }r;)X 3060 0 . (S2 61.3's`' ENS AVE 0302 ? " f LA. C''tL Y22.53 201.ANA MACH CA 9207SI (fySB)79%-1300 CELAI&823 r J;* ;. USE OF PERMIT 1XICAL C F.MC K 100RIMA.TIO0 Ni1sC F;1:L,A��!sUU:7 75.160 SIT. CHARLES .PL r' ; r6 ., V1,19k f4l4"A 4� 54-162 OAK TRi3e • t3I.dR ZINC4 l� TYPE 10volhfV KY;ti'RUCT17SiAI M001 FTC.t1 V10AS ,rk: x' .. ,: 'I /t1..KT.,MT,ION 2f►,QGii,C+O f.S {FC ' Arlz 1. "p: 11tdA �U Cr(3:£'!'Salr C`C)!V't I��Y7G'1Tt)!Y 10,000.00 PEs'g:2.tl4 111.111.1('- 9CFMsa9:riRY s°C}Tt Tt�tZC;`'j'1(�li Jrt •000- 1ki, .'1 0 ;.� S •, ., lr:acs7'l,:,af PEE•.rt>?.,ts� t(il-i)(?i)-•.�ti�•Grii,., 7 R13 CD (.1 K A•r3r?.t11..J N 01-110, X $209.00 APR 2 0 2001 t:':�:z�.>ssgrX�':ci:Eti MY Ncaw �2o'a.eac� CITY OF LA OUINTA FINANCE DEPT RECEIPT DATE BY DATE FINALED INSPECTOR 3, Page / of DAVE STEAVENS Inspection Services PROJECT?C s\ vJ Cs k PROJECT # 62 O / - y 3 ADDRESS. A':s CLIENT C7 tj DATE BLDG. PERMIT# - ARCHITECT VoLsA. Ci4 1rrcrc0fe ENGINEER) t.1 S f� J o 1 E JQL CONTRACTOR'S C L M *4 4 P,Fe r r L INSPECTION. TYPE .� QoxY INSPECTION REPORT.. �'04(.ei l►JC:: `/%]GPz7y+O►JA S1 M P.50j ETF E X 0'. C14EC►lc� : �rZuS4lE i1 ..A•J�' e Lciiw) D,= 1J� i31Z1 A Pt_1 LATr pc`J i4V i� IJ 5T A L.;A r QXJ Q S �.:I G� q i T J.. ' 3 t M P s- v c 5- L�- 3� E a'�I ::.. �` +•a.. �� tZ S 5 a•� �LCrJy;r-t E3 IJ 1 A. Ry-A,i l.;u. (LOC: L..a, 1ir�-rw :� /H a,� .. Z�� 5.-c,�l�rr ►-� /g �,� iS�f - 3�.y aA.kTlzt t�gvdAs It . . a Lc>crS E'�y�,t,5 - 1 aL .-be -PT4 b IPA 1 S' " j °1 VEr.JC.T+^l. ��$ 1, A c - iz'� .• `t�`Tr-1':�3�++,� A li`' ► �l.t=nJGiH: S�tS r�.O r A I:�r+ R eA R L. i 'Loc -iw l `ti . ► u l5 ,�lr R C�..►� E+2 • o� 1. mac.— ��o�:f.5 " <<Z' .� +� %..l 't1.lA ..' IZ,,7 g ' i LE►JGT►�(: �� c1r r� c.oc. 6�10��:5 - t`a..�i�TH .. �4.;A:o�s.- 15E�,�7Ia Dlt� So-►� tkCA(L L%,J ..1 toc? ►' .3�+t. a�.a.. o 15" LE►,JC,T4 ►� --LC3c's• �-Is (:a ��-�(:;a� 0 DS- %'7 tLE_►:�`�7i-f /8,f�1A. �1 3 4•oknA Zv ,c Uj -. �*�� - 64'6':E ta." x H 3/ �,:� i - I s'�.Eyi. H. '/g'br . aEz�.3. : H:oL�S: �Z� �� ,..,:�IQ1• :.1-z0I 'LF_ —rN CERTIFICATION OF COMPLIANCE To the best of our knowledge, all of the reported Work,. otherwise noted, Dihe'locations ubstantially complies with approved plans;.specificatons and applicable sections ofahe building codes. This report covers of the work inspected only and does not constitute engineenng opinion:or project: control: CERT. NO. ©g 59.3 41 (3 " SSD 'I NSPECTOR.NAMEA (Pft Cleary) : f� w�!ZATE 13 -�I� NJ a p� U C�' J INSPECTOR SIGNATU <. s Page of PAVE.STV, V NS Inspectlow'slervlces PROJECTr:; 1�FSTu+as (� PROJECT ,- ADDRESS - Q:5 L'!ST. CLIENT :�L;,�,,E-! OR DATE 9 . `Sixes. eZ cSo I I -.BLDG. PERMIT # ARCHITECT (fo3p, ENGINEER, ,,; ` . ..�.� �.�.�; t�� CONTRACTOR tet_ u��� kiFl< . INSPECTION TYPE INSPECTION REPORT �a�L-rGE A�yc,. �7. _- k"lZ rt�t V Ni^iZZ5 AvZr-'- `7dSi1l_A-i-/ C u [ ; .�.- C- _c�,et-�.��s' A �� �4,�) ►✓� �. � s • . �i mss•! A. -J, -z , . 31 Ll 39A. r, arTTk C► G L , � q I� =AZT t- r lm^ t.,,� C P=' f ,g 4.14 4.14,cg-' 4 D A V Tit t L>7(s 15 t+� ONO:` , CERTIFICATION OF COMPLIANCE To the best of our knowledge; all.of the reported work; unless otherwise noted' ubstantiall com lies'with-approve'` y pd plans; specifications and a"pplicable sections of. the building codes. This report covers .,,,the locations of the work inspected only and does•not constitute'engineeri ,g•opmion or.project.contiol. l r CERT. NO. l- O ° INSPECTOR NAME -A Ll 5 ":i 1 n , ; (P 1 - -ILDATE • , �1 TL._ r�i 1;7 C70 .i INSPECTOR SIGNATURE ,✓ E v ,