0104-240 (BLDG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H ° •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.
C :5 M License # Lic. Class Exp. Date
0
cZ ti Date Signature of Contractor f
(D_0r;
i— c
_J (DOWNER -BUILDER DECLARATION
J
W W r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ co 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 exclusiwely contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
C")() I am exempt under Section
LO B&P.C. for this reason
N Date Signature of Owner
ON
a Q WORKER'S COMPENSATION DECLARATION
p m
Cc I hereby affirm under penalty of perjury one of the following declarations:
H p () 1 have and will maintain a certificate of consent to self -insure for workers'
X W u- compensation, as provided for by Section 3700 of the Labor Code, for the
000 J Q performance of the work for which this permit is issued.
Q U (• ) ' I have and will maintain workers' compensation insurance, as required by
O Q Section 3700 of the Labor Code, for the performance of the work for which this
LO
d rn H- permit is issued. My workers' compensation insurance carrier & policy no. are:
1, Z Carrier Policy No.
oo d CAI. SNI FWNITY 'W',106.2174A
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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with,those provisions.
Date: Applicant i
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 Ouinta, 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) `' `' `'�� �� Deli",
BUILDING PERMIT PERMIT#
LOT 0104-2Q TRACT
DATE VALUATION�r�YY��
re
$20.00
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
.P(aA. WFAST f.tE.`�fJU.T AL AWiC14310H
nom., MAR PACIFIC GF.NFIZAL C.OWRACfO
PO BOX 1060
462,7M., INS AVE, 0.302
LA Q(, TNT k CA 92253
u().L AKA.13:"'IIH CA 92075
(8523} 9Z 1 m) C111.4 5823
USE OF PERMIT
WOW. OFFICE MMIRMA,TION
M.', (':'F.I_,%,ANE,0U3
'75 -10 ST. C11ARLiP..9 PL
K4 -69i, ao-697, go.,w "eft ao-** O.A.E: TREAD • ilUILI)lNil df>; TYPE
0 VOLUNTARY STRUCT URA.], MOLMRICATIOW,
VAL.UAT)ON A000.00 LS
NS1:IMATF-D COST O'0' CONS~TRUC7IOH
20,000.(X)
PERRY. FEE 91TW"RY
CONS77tUCTIOitd W. 101-000-418-000 $207.00
ST1iOW MOTION ng- WK) 101 -0()C) -241 -OW 32.00
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DU LESS PR, YWD � WN
Rmff FIE 3�; , DATE, NOW
UT(YrA
j
CITY OF LA OUINTA
FINANCE DEPT
RECEI
DATE FINALED
INSPECTOR
DAVE STEAVENS
Inspection Services
PROJECT c, A �� : • r�1-aA5 t
ADDRESS 9b - (DQ,1 _ L„'1,*10 3.1,)to oAK uZz
BLDG. PERMIT #
.ENGINEER �u )r� -(;R 1161 E -'fJC .
INSPECTION TYPE
Page ( of _ I
PROJECT # vo t - Z) 3
CLIENT WE i 14oA
DATE // 5 E P /
ARCHITECT GO c.Bt912cN �T�-LTu 2t
CONTRACTOR mfl2 �eIFiL
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, specific'
tions and applicable sections of the building codes. This report covers
she locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. NO. 0g`5,1' A y8 - Sb INSPECTOR -NAME _1)AVt. -'S�TZA JE►J
_ Prim Geary)
DATE S E l a J O( INSPECTOR SIGNATURE\ ',^�
Page _� of
DAVE STEAVENS
Inspection. Services
C01 -
PROJECTC.,8 vjzs-) piiAsc I A, PROJECT # ►- O 3
ADDRESS ED -(p 9..4G91 . 70 3,7o 5 CLIENT A H o A
::*1J,,CrZ lie 5 &.ac -3 C,k r3 DATE 7 S C? r Zyd l
BLDG. PERMIT #
ENGINEER SAJ0iE a,3c._
INSPECTION TYPE
ARCHITECT Go t_B A -4,2,-Hl Je-Iec.ri2C'
CONTRACTORI G C_ th R 2 /DAcir-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,
--substantially complies with approved plans, specifications and applicable sections of the building codes. This report covers
—Pe locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. NO. Op7.3
INSPECTOR NAME�49 d C -S EA Je Pis
(PrimDATE 2 St P c;2 INSPECTOR SIGNATURE \
Page / of a'Z
DAVE STEAVENS
Inspection Services
PROJECT �GN Qv % •��1PsF t�R
ADDRESS & 01, (0 9 7, i p 3� j(( d
QA4c.?2t� 3�a� 3� °I t�-LRJ
BLDG. PERMIT #
ENGINEERju,,--,.j SAJvt E Ta c—
INSPECTION TYPE
PROJECT # 400k-0-1
CLIENT�+� t�r.SZ CoA
DATE S !SE t'7".
ARCHITECT Got -Wk i�R.cti.1TEc�t,2c
CONTRACTOR L m A it A t
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
the locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. 40.D�, - :SO INSPECTOR NAME �. J A t� ��%���i t) CLI S
nt teary)
DATE :5 S t •T. .Ltd 0 INSPECTOR SIGNAr