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I hereby affirm under penalty of perjury that I am licensed under provisions of
�^hapter 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
r3:« x.52 TA HFI,'
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).
S>c.-J 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). r r'
I am exempt under Section B&P.C. fpr this ,eas fi
Date +� Signature of Owner;,
WORKER'S COMPENSATION D1 A4A ATI0N
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.
(`;y 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 '31'A7'1, F;.f�d:C? Policy No. f?�?O1tdR"9atfsu0i }
(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 Secti. 700 of the•�tabor
Code, I Sh {I;fo hwjth comply with these provisions. ,
Date:,-_--�..
Warning: Failure to secure Workers' Compensation coverage is un awful 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 authoriTe representative's of this City to enter upon
the above-mentioned property fgf inspec Ion pu(poses.
Signature (Owner/Agent)' -✓� ,c n<� ate r
,BUILDING PERMITOX
! I - '14 69
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS .t'3T.F)" Ae '° p .i' ! Y �!,ss 5y-717 7
APN y;
OWNER
CONTRACTOR / DESIGNER / EN (NEER
11. OX 1(160
2,133 FXF;,. 250
(76Tj),l.'5-1wt0 cIki.i.I 518123
USE OF PERMIT
SL.70. 21: 5�1 3(t9� fd •3f15„ ,�-Irlili. 54-7V, 'Joi.,tmr.AR Y
AJTT'ft'U T U' f, Mtn i)1F'i°
1: Y ,: 103 -000-419-000 M00
S"I'F OW0 MOVION PEE - ?ESI.f.J. 101-000-24 ; -000
FEB 0 3 2003
CITY OF LA QUINTA
FINANCE DEPT.
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RECEIPT
DATE
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BY ".�'
DATE F AL
8
INSPECT R
DAVE STEAVENS
Inspection Services
Page of
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PROJECT(�t -1 ; - t-' c.e 4.%S PROJECT #
ADDRESS y-7?7, 9!P/ Ao -5,4
v CLIENT (faP1 AIVA
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BLDG. PERMIT #
ENGINEERD,.�, ,..a ..i 7�F Jv r e- a#J c -
INSPECTION TYPE
ARCHITECT �(J&A3^ jq-1?oJ
CONTRACTORDCL
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.
f CERT. NO. INSPECTORNAME ti vU
��\ (Punt Clearly)
DATE /.I /t/ I c� r1y3 INSPECTORSIGNATURE,"N �ti_• c /�h-
PROJECT
DAVE NYEAVENN
Inspection Services
ADDRESS �5q- 9q 7 oc'a f, 6?0
BLDG. PERMIT #
ENGINEER
INSPECTION TYPE
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Page of
PROJECT # c; 00
CLIENT s r HOA
DATE 9 M A Y cP oo. Z
ARCHITECT .Eno, Q.'!S1q AZC-P
CONTRACTOR 7,0i C— aft VNil ?AC'r1C-
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported:work, unless otherwise noted,
substantially
bstantially complies with approved plans, specifications and applicable sections of the building codes. This , s report covers
,he locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. No. e.) INSPECTOR NAME
-%(Print Clearly)
1;1,4 V )ao INSPECTOR SIGNAT
DATE URE�-�'