0104-237 (BLDG)I herr' affirm under penalty of perjury that I am licensed under provisions of
Chal. (commencing with Section 7000) of Division 3 of the Business and
Profcsslonals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
7 152 Y's
Date Signature of Contractor
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 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
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.
t;/:1- 17.'Y :•l: f;ti2f';"i1.�1.
(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.
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 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 cr 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
MILUINU rtHIV111
DATE VALUATION
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JOB SITE
APN
ADDRESS01
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OWNER
CONTRACTOR / DESIGNER / ENGINEER
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USE OF PERMIT
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CITY OF LA OUPHA
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BY
DATE FINALED
INSPECTOR
DAVE STEAVENS
Page ;2- of Z.
Inspection Services
PROJECT:��e,p, u) �-sg - W,�,-Scr - I A PROJECT # t - o ?S
ADDRESS A S', -C-)k\.
BLDG. PERMIT #
CLIENT '�6.N LoSt;—\ t4oi�-,
DATE. -:)i2 Am-" ;aaol
ARCHITECT.exlo�.ZA 'A1XC*4 01 -0 -?C -Tu. iz ic
ENGINEER3\AoK\ CONTRACTOR.--%)S� oy\AIZ -';)Nc %;r%
INSPECTION TYPE
INSPECTION REPORT'
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
subst4ntially complies with approved plans, specifications and applicable sections of the building codes. This report covers
Ohe loc�tions of the work inspected only and does not constitute' engineering,opin ion or project co'ntrol.
CERT No. nes(M 4A -t—> INS . PECTO . R-'NAIVIE'�AVIZ
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DATE AU6, ;ZQQ/ INSPECTOR SIGN ATUR�E-Jk�
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Inspection Services
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INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported
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✓)he locations of the work inspected only and does not constitute.engineering opinion c
r
CERT. 40. n L/A - INSPECTOR NA \ E I
DATE INSPECTOR SIGNAT
rk„ unless otherwise noted,
)uiloing codes. This report covers
oject control.
. .� �,-. .r-w>,r..r.::.�,-,rr +r7,1:._.�„w .y A..��+M1r3i.4-.V�1.✓'"r:w.,f'��f�'.r-..v-r�r''`r'.�:.-•/`L+'Mi.-".�+�rv�:,;ia+�r-Tt'�+'Ci''f'-.-�`-�-"�'ti--�•..i. .-�.•.:-....
DAVE STEAVENS
Inspection Services
PROJECT #
ADDRESS $D- G 15 go (q
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BLDG. PERMIT # -
ENGINEER',X_-�,a Q S+^J p �e k w3 c -
INSPECTION TYPE4�-f
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CONTRACTOR P E L M A r2 it c (r - (c.
INSPECTION REPORT ,
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise.noted,
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'he locations of the work inspected -only and does not constitute engineering opinion or project control.
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise.noted,
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'he locations of the work inspected -only and does not constitute engineering opinion or project control.
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