0301-359 (RER)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
:a 15 2 1411,ra ' c+ s t f a
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).
(XI 1, 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. Or this teas fi
Date' � . Signature of Owner,
a v WORKER'S COMPENSATION DECLEYF ATION
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 it9 AT ' RUM) Policy No. 0401),UNIT i 00.941 S
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if should become
subject to the workers' compen sation$rovisions 'of Secti• 700 of the.•Labor
Code, I h 11 for,hw th comply with th4e provisi ns.
Date: - 2 % 2 Applicant ° c._.. • �
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, indemnity
& 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 representativps of this City to enter upon
the above-mentioned property fgf inspec Ion pur`p'oses.
Signature (Owner/Agent)"- ✓ " Date._"
BUILDING PERMIT
DATE r' I VALUATION LOT TRACT
JOB SITE
ADDRESS %1q.� 1f . 2.1.
APN r"<,
OWNER
CONTRACTOR/DESIGNER/EN (NEER
PGA. WRIT
ML MAA 3--'MT`11C(MMOW,%C014M,.AC4".
1'' (). "0 MI.' 3 C.ii`iCD
25 3111' " C f ITH yti`O �: 3.' AI(xIT1A Ai!' `uYJ,'Y 0
(�A 9225:}
C141, 9200
USE OF PERMIT
COOT. K—P fill, ISUI
BLDO, 21: SA��09, �i,.SflS; �!-tr,�il;..`1<b-TVZ +%Ot.,t33+T'II`.AR11
STRUCTURAL MO-Dii%j4'A`Pt.C" NS
RXITMA I.M. C(' M.",0F A:Oi''srN"T911MION
PE11 N1r1.' VA" f MMA;
C(5PO.3' RUCTON FI?t, 10 1 _000-41 FI -00111 n6,'7 00
S TF:t7NLI tdtD'I' IGN I'" - T?..M19-3. 101-t;?) O-, 24 S _000 $2.00
FEB 0 3 2003
CITY OF LA GUINTA
FINANCE DEPT.
,9012% -TOTAL IC0.1MMI:it"):'kw+N AND 1;'`i.,.w armcxT
x .1ik'�'�9 :i�1�1�i•��,t3� 1<'t•,,,�';�
�'�. tltx
%.'F YWIN U'.�'10;V S:Lt'UR N( O
S20%0hi
RECEIPT
DAT !'.:./ - rt
BY
DATE F AL�
INSPECT R
> 1�• � of S ,:l r F: v �
f 7 77
Page of
DAVE STEAVENS
Inspection Services
PROJECT KA c_cc e'alaS ,`
ADDRESSS-,(/- 7f?7, J�o/ p�p T 69
BLDG. PERMIT #
ENGINEERDtA � a
INSPECTION TYPE
Ie_._-7 -
PROJECT # a: C-0.3 - di
CLIENT A, -A • t.Ji.'Sr W,004
DATE , /t7 ^44 ;34,4>3
ARCHITECT G 4-s3A A-I?cj.J
CONTRACTOR LI £L. -*Mit 14 c ► ,eir,
INSPECTION REPORT
A it r . Il_ -
."i-AAA - -7 !C 7cQ1. `fr JA
_1'Tra It - : s -7 • SLIoCA< /`SAr=Te- 12 ,rI,✓t9 PL `r
Cot"tit LATA,
J 1 h ►� 1 ( J S ` " �ii 1� rl� A j t5 5301 A A s f., r !J - m y d.. L► 7'�r
/7 ls,q 7 7A." .4
i),s%4}07'rrxJil�A.1 r' aiFZ�w�
,r
' CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported Im, unless otherwise noted, • . ;;.
ubstantially complies with approved plans, specifications and applicable sections of the building codes. This, report covers
e locations of the work inspected only and does not constitute engineering opinion or proje t. control.
CERT. NO. 27 3 `lam j�j3 INSPECTOR NAME
DATE INSPECTOR SIGNA
Page of
_DAVE STEAVENS
Inspection Services
i PROJECT 1 taJ+r S i - 'La Gt�.c15 PROJECT # c�yc 3 - U
ADDRESS �'`�•��y�_ $03 g�� CLIENT ?GA WE ST HOA
r cl ,t 7�s s Lc +• a I a; �w 5 DATE �} M A Y Q po. �
BLDG. PERMIT # ARCHITECT C'x e -AA A Z C F.►
ENGINEERRCONTRACTORZ1 C L?A at r{ 4
INSPECTION TYPE
INSPECTION REPORT
�S- 4� I'S- -1- L -?O's 8 LVcK4
TAILS- T /S - -7 --
1 '
64*
(. eDen it L ta" ra- f
c
R
S
s
fC
f
' S
0.
a
Y
CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
0substantially complies with approved plans, specifications and applicable sections of the building codes. This report covers r
he locations of the work inspected only and does not constitute engineering opinion or project control. s
► CERT. NO. _( /?3��C ' •SU INSPECTOR NAME
DATE ^4 y lJO 3 INSPECTOR SIGNATU�+
777�77 �7 7j, �77- 7.
X
DAVE SrvuAVENS
Jnspection Services,,
Page of
PROJECTP(,Fk LZrsT,-LC- PROJECT # ;2003 - -09
ADDRESS T'O- 74 53071 S%'A t S sel CLIENT P6A WC57- 1404
Boa 4 AA► Ap ~ ..DATE 9"t IVAViC'k/ a vo 3
BLDG. PERMIT # ARCHITECT 6-pcj3A A(Zr—q
ENGINEER to AjtJ 15A%A;YC- CONTRACTOR -OCL *+IA9 PAC-Ifrle
-
INSPECTION TYPE
INSPECTION REPORT
N'
IN,
4W
I —T tN S - "S, A J (3 AJ r% I I J(. " o►h t --L r
►
r
-7 &Oe- 3S* LI'7-
F-,Z007- P1 1A 4 1-4 t-:�1,-TH tAc.
3A A tin k),e rL JC, -
4 -3q
&0-C9/x)c. L .7v'lo
CERTIFICATION OF COMPLIANCE:,To the best of our knowledge, all of the reported work, unless otherwise noted,
substantiallyj
qmplies wits approves plitns,specffi lit covers
cations and applicable sections of the building codes. This' repo
IoCationS�V)hft
the pec!ed dnly.and does not constitute engineering opinion or project control.
CERT. NO. INSPECTOR NAME 4dt:' 5-4-r") je- 4.1
DATE i t0l4iecW CaO INSPECTOR SIGNATLRw- g.4. :AP21
44�1