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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
770940 03 9 %litc
Date Signature of Contractor
OWNER -BUILDER DECLARATION
)'113 1i2(
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
sa)e (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&RC. for this reason��
Date j�y['�� % ; • ! 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.
2117TF lrUiNV) n ,fj ? Sti101 fy1
(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 gII forthwith comply with those provisions.
Date: -"T/ ' / ' i Applicant f f
;'
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 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.
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
_ _.— ----I
BUILDING PERMIT PERMIT#
DATE VALUATION LOT ��I�Y.�1< TRACT
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/EN INEER
3'trrA 1X1? .C'RMCJT1 ..311MA.L 110W UWMR0 P
88 MAERAi.'15.><tC OFMC1,WC.
1*11 Q EXXX 1(*0
83-:197 PNACH ST.
L& f.;iU'.s -411
NMI CA,
'P76
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Lq
USE OF PERMIT
1,
f yR.00IF WITH CLASS A. MA FRI.Al.-S- ULL71Z 72:
10D
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1 8 2001; ,
V A1..,U.AT)0'A 1,500.00 I,3
CITY
OF LA (QUINTA
FIN
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T;CIB-'LOTA.L'. COUirfTt.Cir'tION AND PL" CHOCK
$30.00
:G ZI PRE -PAID M,3
$O.00
11 C TAL rKlWCl' Thr EN DITE NOW
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RECEIPT
DATE ;
BY
DATE FINALED
INSPECTOR
OAK- TREE -
Page ( of i
DAVE STEAVENS
q4 _ Inspection Services
PROJECTZ�,A U�tST z;)NA St
ADDRESS
BLDG. PERMIT #
ENGINEERt-
INSPECTION TYPE
PROJECT # - 02 U o 46 O
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DATE 17 M A y
ARCHITECT A }a ICH, TLzrue�
CONTRACTOR E j- v l A e t%sc i'ri c -
INSPECTION REPORT
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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 report covers
he locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. NO. aIR69. 3 T QQ S
Q INSPECTOR NAME 1)A, JC re.A J C)Q
,.- %(Print Clearly)
DATE. P7 INSPECTOR SIGNATU
DAVE STEAVENS
Inspection Services'
PROJECT�� �,OtS i _- "Nmz IA.
ADDRESS
BLDG. PERMIT #
ENGINEER
INSPECTION TYPE
Pagre,: � of
PROJECT # o2 c -D 1 0 3 .
CLIENT�Uf� L,),E'ST kAOIN
DATE l Cg MfN-A ;Loo
ARCHITECT GO -LIP,
CONTRACTOR
INSPECTION REPORT'
I 1AoLjc-s - l 1,-7P'r%-A bifb,.' Robs 11 LC_QC.77t4 7/e 'b', r A
Loc- Aot-C -
5-4:- 67 2- 1+- iale 14 .0A#4-r-Z'EF_
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CERTIFICATION OF COMPHANCE: 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 constitute engineering opinion or project control.
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CERT NO. INSPECTOR NAME a �tA ij
DATE ry\
INSPECT'ORSIG4i'UFqA
DAVE 8TEAVENS
Inspection- Services
PROJECT
P� JEST W s� A
ADDRESS As L/ s T t A
BLDG. PERMIT #
ENGINEER u til
INSPECTION TYPE
s`i -�3h0 • oA�TiZ�tr -
Page of
PROJECT # _ tP av / - off, 3
CLIENT. P(SA
DATE /S M A
ARCHITECT 60 LG A ''A /Z c. TCGTu e'
CONTRACTORS C L M A' R Pi4c •rC
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, uniess'otherwise noted, .
substantially complies with approved plans, specifications and applicable sections of the building codes. This report covers
e locations of the work inspected only and does not constitute engineering opinion or project control.
CERT N.O. 0IR1:5,9 3 N 19 - S,0 INSPECTOR NAME JC A J G J 5 .
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DATE /� /W A 7 L o p INSPECTOR SIGNATOR
y Page(_ of
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DAVE
. S EAVENS
Inspection Services
PROJECT -?&A f ,jp- s I A..
ADDRESS &S
BLDG. PERMIT #
ENGINEERQI J0--5Aj01 1, -,IC -
INSPECTION TYPE�oky
PROJECT # c52 um / — 0
CLIENT +)4-A LJEST 14o
DATE
ARCHITEC'6,pLB6,4 Tt�n, et
CONTRACTOR,/) t G 1n q (? c 1 F/ C -
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work; unless otherwise noted,- i
'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..
CERT. NO. SgB - SD 'INSPECTOR.NAME 1_ }
.. -
DATE �/ /�� y jj� INSPECTORSIGNATU ec�Yi
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