0104-240 (BLDG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Fes— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
(7; :) M License # Lic. Class Exp. Date
�0
LLJ
cZ � Date Signature of Contractor
(D0.",�
J U 0 OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a License Law for the following reason:
Z_ ( ) 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).
c") () I am exempt under Section , B&P.C. for this reason
u')
N Date Signature of Owner
ON
d Q WORKER'S COMPENSATION DECLARATION
p Z
Q I hereby affirm under penalty of perjury one of the following declarations:
Q () 1 have and will maintain a certificate of consent to self -insure for workers'
X W !L compensation, as provided for by Section 3700 of the Labor Code, for the
J Q performance of the work for which this permit is issued.
Q I have and will maintain workers' compensation insurance, as required by
0 Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn H permit is issued: My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No.
g(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
3 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 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.
co
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
Q
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's ��'-' '
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0104-240 TRACT
$20 000 DO
JOB SITE
APN
ADDRESS
0AVIN.FE
OWNER
CONTRACTOR/DESIGNER/EN (NEER
PG'A. WM RR.TD&TiTAL A 80CX.Ri.110H
riirJl., MAR PACIFIC C3F.,§&RAL•, C YWRA(.'"T�0
F0 L' X I No
452 ,Y1IN1019 AVE, 002
LA QlMn-A CA 92253
SOx.,ANA.l3EACH CA 92075
(858)792-15()0 582.3
L,OVAI. OMCF, INrORMATION
USE OF PERMIT
t�11it�TL ,,At ?t7t1
•75.160 ST. CHARLA..9 PL
Ifo-►iRl, $9-d97, &.76,&80.700 O.A.Y.' TREE - BVILMNOX, TYPE.
9 VOLUNTARY STRllr; TURA1, MODIFICATIONS 2
V A:I...UAT)ON 2P,000.00 LS
wrimAnm cogr or Congmuenom
291000.(x)
fliazm f FIT fl'1T61AMARY
fiOW"tUCTIall M, 10)-000-418-000 520.00
ST'Rt" NO MOTION FEE - RESID 10 WRYLf-2,11-000 $2.00
�; .-�c�• , i.oOTII (riaH AND PI• J*1 CT-WX
;$209.00
DL ISS PkI:•➢'ATD I
50100
(+ T(YrA IRMU FUN DIKE NOW
Ahl
CITY OF LA OUINTA
FINANCE DEPT
RECEI
DATE FINALED
INSPECTOR
t Y .i� jr t ., ».n ,c ..• _ � ...: j. :.^aSl.�-'y,�`+ %''A�+- ..
' �
''
.-• ...�
Page t
of
.
DAVE
STEAVENS
.
1. Inspection Services
PROJECT �� A z ." • �>`lA5 R
ADDRESS Q0 - to<k\ . L��-\ Mal3."l�i.
BLDG. PERMIT #
ENGINEER uw)rl A ,I A t E rAJC
INSPECTION TYPE
PROJECT # acro t - 0 3
CLIENT ?6,4. LJE ST W o A
DATE l( SEP i o9yo i
ARCHITECT e!� 0 c.8 A 14 2cN iT,'(-Tu 2 t
CONTRACTORL fA A2 JIA O -I rl,c -
INSPECTION REPORT
at.1 .)foo ---s = fiats ;kZ klklLj.��_ Ati� STiZ}��t�tJL- C'�ry� C.r.Tc,
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. O gS� g' `>�B `C7 INSPECTOR NAME l J; -r,,)
_ PrIM Cleary)
DATESO-
INSPECTORR SIGNATURE\`
..
Page of
DAVE STEAVENS
Inspection Services r
PROJECT?C,A \J -E5 -j :PHASE I & ,
ADDRESSQD -Cp 9 /r 69'707,05 .7o 9
SdU'CQU&5S dc0L 36, S ?cOvnJ
BLDG. PERMIT #
ENGINEER I WJf3 SA JCi E =13 C -
INSPECTION TYPE
PROJECT # o'? �-0 r - 0 3
CLIENT f� A w.Tr H 0 A
DATE.7 .S f ? T Zoo/
ARCHITECT GoLBl/1CH/J�cTu2c`
CONTRACTOR16 L /h R e- f Ac -i= -r c -
INSPECTION REPORT
BF -X%=
14 C 7' �/S L -7JS
-`A I LS3 1 5 ' 9 1� c.c) C K t RJ G �! i] {� 3S _ Ccs r+, Lc -r
r
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
the locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. NO. 7.3 5 INSPECTOR NAME A
� dt� / . (Pr'vn
DATE St Pa INSPECTOR SIGNATURE�� Ocs.�-
DAVE STEAVENS
Inspection Services
PROJECT �(,N �Qec; •��1PSF. to
ADDRESS & (6 I t 69 70 -f 0 3.10 9
BLDG. PERMIT #
ENGINEERjv„, o SAJo E Ta L
INSPECTION TYPE 12 -?Ox `i
Page / of o2
PROJECT #-2 o 0 t- 0 3
CLIENT
DATE S SE P 7". loot
ARCHITECT GoL:�Stl�
CONTRACTOR IEL m A 2 , r
INSPECTION REPORT
L.A_ N_'T k o N3 �. � �c z -= C_ --gq.-S,
'ILAQ 3 .
•
OL15. (I LEO L; -r t i D tA.
10
A. R 0 D -f4. Lc:yteT�t xi3
IZz,o,,m. Q)x-5T t.-14 - 1 LUL• \40E"TA 1�DiA . IDDM - I'l l -d014 H !B •111A
-t ryrts'it- 2 %_uC-S - Ro'—c- i�L -t /4 a Its . z00 3 - IL ca" -.4
gt7-..r/D3 t�41caEr_ ?LA ►J N D, a �Za D I
1,OLCS- ��'D��iH 3ly
IC &-„���.2�oS-ItrLylattN S���D,g
ReAt T < ' Lt) CS - t1
Z2 4ka C.As-t L. v - t I...uc — -Z-
ZO--109 MKT eC PAO 3
12CA12 U-7es LI <) 1 Lo(- - Hoi-A • ROD - 1 6 .)►A
i`,o(.r:S- la. �E,�TN lD+A fkoDS - I'lLti ,- -rP '/6 .btfl
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 reportcovers
✓the locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. NO. _ e!5?2C g - :S -t' INSPECTOR NAME � A ✓ � ��tZA LICA✓ S
DATE 0 0 / INSPECTORSIGNATu