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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 7!1940 C"W HIC,
Date Signature of Contractor
OWNER -BUILDER DECLARATION
a1illi 9111,,e
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).
(s1) 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 4
Date / ; h % 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.
( ) 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.
STA.TI? P;UNI) 2.114-(°fr-G!t0)?V f
(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 forthwith comply with those provisions.!
Dater Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnity
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days. from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purpose$;
Signature (Owner/Agent) f f, i•' `. ! ,�.' Date
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BUILDING PERMIT PERMIT# 3;
DATE VALUATION LOT ()] .60 TRACT fl
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ADDRESS
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OWNER
CONTRACTOR/DESIGNER/EN INFER
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as T?;PvZmajz ROOFWcf, INC. '.
83-597 PEW -11 ST.
T:,/, qf)'ul..A
0,010 CA 9220,lil
(760)347.9869 C'i3&8 '597 3
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USE OF PERMIT
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION I DATE INSPECTOR OPERATION DATE INSPECTOR
Set Backs
BUILDING APPROVALS MECHANICAL APPROVALS
I j Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans I
--�— - F.A U. j
i Corepressor
_ Vents I
Grills
I Fars & Co � of
U", W
Condensate Lines —
I
'r-
�a�V P=JOL S m SPAS
I pprow2l to Cover
-
Main Dr;:ir,
:�� � -
Equipm::nt
Jnderground Elcoria I ��
Jnderaround F'Ibg. Test
- t Ga,
Gas
141aste Lrnes
- - —
Water a;s:, .r
rlumbino Tot) Om
Shower Pans
Sewer Lateral
Sewer Connection
Gas Piping
�-
Gas Test
Appliances
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G F. 1.
Smoke Detectors
Temp. Use of Power f
Final
Utility Notice (Perm)
COMMEN I zk:
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0-4ItY
DAVE STEAVENS r
Inspection Services
PROJECT ?t A, Qt S t (A
ADDRESS A 5 c- t S-1 �g--
BLDG. PERMIT #
ENGINEERD "Q tJ SA j o I E 1 yJ <-
INSPECTION TYPE
Page I of
PROJECT # tP
CLIENT '?�-4_WEST- 1yo►4
DATE I rYl A Y c7 0 0 1
ARCHITECT t2C.M IT Epi co2C.
CONTRACTOR 1 c: L MA 2 YZ)q u f 1 o
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
ubstantially 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.
CERT. NO. "R!!S--93 41A- 5 D INSPECTOR NAME
Clearly)
DATE 1—tj�`P two INSPECTOR SIGNATU
�..:. Page 2 of 2-
��'-�= DAVE STEAVENS
Inspection Services
PROJECTkz> ?D%,,4S6 /A
ADDRESS- -"'A 5 U S 7 -CO
•w� 9 ��o
BLDG. PERMIT #
ENGINEER u ►J 5 ✓D / E / nJ <--
INSPECTION
INSPECTION TYPE
PROJECT # -o3
CLIENT �G R r✓J cS f �/o �4
DATE
ARCHITECT G0L301 Aec4iic.c-Tu.,e>s
CONTRACTOR JEL
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE: To the best of out knowledge, all of the reported work, unless otherwise noted,
ubstantially 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..
CERT. NO. Q / 3 �- (� INSPECTOR NAME ^.. �) A �'r . S� a J CJS
DATE 6S /,11,4 �toot INSPECTORSIGNATUFiC�__4_ar 1 -
Page of el..
DAVE STEAVENS
Inspection Services e �Y
PROJECT' 'C=A \A) e,ST- '�Nfl SE I R . PROJECT # a o - O 3
ADDRESS A-) U $TIFb CLIENT ?6A WEST r4o ft
BLDG. PERMIT #
ENGINEER,D J�.) SAb t E :rOG-
INSPECTION TYPE E-?dX `(
DATE Kv M A `f .2001
ARCHITECT ecz�A 14204 PrCC-nu kE'
CONTRACTOItJGL MA2 fes- ACt r1L
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
iftubstantially 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.
CERT. INSPECTOR NAME & JG ZAQ/&A.)
(Prtntg
DATE ( 9 Aq V (900 INSPECTOR SIGNATU Q z+yt early).