0109-161 (RR)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
7709440 C31 '1111C ) 11.0i1t(
Date Signature of Contractor
c
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).
I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am ex9mpt under Section , B&P.C. for this reason
Date ,>�/e .+� / / Signature of Owner ref t.. `•' ,�,
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.
S'1'..TF F>,33 E't:tRIt- ii0-000 901
(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,
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 foghwith comply with tIt Ihose provisions.
Date: " i Applicant `�, f r ?'
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.
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. %t
r/ p i f .
Signature (Owner/Agent) Sr' �� 6s '` _/ t Date
BUILDING PERMIT PERMIT#
`
DATE VALUATION LOT �b�ij;�o-�,��
TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/FN INFER
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1138 1WMd>U) RC)C)n- NO, 19C.
I".0, b11)'K } ct00
63.597 PEACH SY,
LK 4atlOXTA.
WD10
Cts 92201
CM))347-9869
CE q 5978
USE OF PERMIT
1
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1 8 2001
`J P.}:1.11#T).(')13 3,0E►,tit(f 1,.q
CITY OF LA QUINTA
FINANCE DEPT.'.
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1;%I0.00 '
P1Y1;.t)t.),1V FrE, '101 -OW -41 t' -O(K) S�il.tlU
STA-` 10TAL. (1,0141ITM.}KITION ANI.) PLAN Ci111,k1'K
I
$30.00
:1..x':915 PRFPAM PM $0.00
J'OTAL 1PFZ4?t4C'1 nXIS DUE NOW
1.
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
DAVE STEAVENS Page of. --(—
Inspection Services
PROJECT�A —%�PV4ASIC
ADDRESS L S en -,`3
BLDG. PERMIT #
ENGINEER
INSPECTION TYPE
PROJECT4. c:2c-)v46-(0
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DATE 1"7 M
ARCHITECT
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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
Ane locations of the work inspected only and does not constitute engineering opinion or project control.'
CERT NO. 0 1969 3 4 8
INSPECTOR NAME
(Print Clearty)
DATE -U
INSPECTOR SIGNXrU
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Page , of
DAVE STEAVENS
Inspection Services
PROJECT }�=p� l Ozs i - Nmz 141.
ADDRESS
BLDG. PERMIT #
ENGINEER�.iNl
INSPECTION TYPE
PROJECT #
CLIENT p f tit ST R
DATE
ARCHITECT 60L,IN f ac.'"
CONTRACTOR
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 applicablesections 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. Oe-Sn% 3T6 ' S-0
INSPECTOR NAMEI
DATE � M#�� INSPECTOR SIGNATu
J
Page. j of
DAVE STEAVENS
w Inspection- Services . :
PROJECT�tJ CST • _?H A SC � N
ADDRESS A ss L/ S T t i>
BLDG. PERMIT #
ENGINEER,_
INSPECTION TYPE
PROJECT #a � 1- Olt 3
CLIENT. P6,A, W G S i O o tl
DATE /S' /V1A
ARCHITECT C_--1IyLAMCJI�.
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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
,zhe locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. N9. O'RSg 3 N - S'O INSPECTOR NAME t J6- J G X15.
�/(Pri1
DATE %� /Yf 7 L o O / INSPECTOR SIGNATL)