0301-357 (RER)I hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N co Professionals Code, and my License is in full force and effect.
5 ch L!cense # Lic. Class Exp. Date
cOZ Date Signature of Contractor
co t3
J UOWNER-BUILDER DECLARATION
LU
r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
In 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 &; Prof$ssionals
Code). '/ I l
N() I am a emp funder Section B&P.C. foT this re so�
N Date`, -:e Signature of Owner.._•-�•,....- r -,
CL Q tf WORKER'S COMPENSATION DECLARATION
It Cr I hereby affirm under penalty of perjury one of the following declarations:
LO O () 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
O J Q performance of the work for which this permit is issued.
m Q (� ( I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn I— permit is issued. My workers' compensation insurance carrier & policy no. are:
00 Z Carrier ' TAI, .F'4t)ff) Policy No. ft�f6t3j kJ&.Nf`1`GP0941 v
(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 thpt if/I should become
subject to the workers' compensation provisions of-Sec�Y1O 3700 of the Labor
Code, I sh II f `rthwith comply with those provisiopn.�,..,_
�. Date: '� ;;" Applicant .j
Warning: F ilure to secure Workers' Comperiation coverage is unia%61 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 authorize representatives of this City to enter upon .
the above-mentioned property for insp ction•puoses.
Si natureOwner/A enf f ' iDate,} F
BUILDING PERMIT
%+
DATE VALUATION LOT '
TRACTJOB
SITE
ADDRESS 1:Il:�aD( 1•. 9 JLi.:T �a'oP:.E���`S
APN
OWNER
CONTRACTOR / DESIGNER / EN &NEER
f' { i f
1 , :�S..:ti�� :Ex.+��<.�:1•°€a
LA i,�3 �t,C't�1Ada CA 9 22152* e(_',;�.5.�.�.F4•C�.jiY�
�:�:'�!".• ti�1."! �'9 C -IN 921007
USE OF PERMIT
)fS..i'.)i,:t, 19: af4.1NS1 tiQ••8:3�:N7:�:9yr.'�!•f'l;a�, �t�'".,f.1?�t'1'��'Y
>f tflf"1't� t�1 M ti: IRCAi'IOW121
VALUATION ir,
E'5'XWATK
1i Fvp s:cAdAl'i�
10)„()f 0-418..000
:;•TRCYRO ARC:t'f[ON F&F• i G',;iCi 1.0 1111:100- 714 f. _:j )0
D
FEB 0 3 ZUU3
O�` pU1N?A
CIFF INAN�E SEPT
i'it..J e••`:1�'.�a".+'5.�:: Ea'S'3I�1'i':1ti?•f.II:;'s_'!.Yid.J�.:i,�`.*.�,t;LK1.`•1 (.�'.:-�.��'.{.:v'K ..
:1'€1:d.��:, .l?:t:;12�s�:� f' :q� >�',"�?�S ;c:ke3 j�; .�f'n��•
sr-:�ftr,�.f�? F
RECEIPT
DATE ; f
B>/^""'
DATE F AL
INSPE R
f
Page
of
DAVE STEAVENS
Inspection Services
PROJECT -4-cesc,yo s— PROJECT # cpwo 33 - 0 1
ADDRESS 3'i, 9 312, BAR
40- le, IQ
CLIENT ?�,,A Wc'--7- I -40A
DATE pnfl,/ dvo 3
BLDG. PERMIT # ARCHITECT 6o /- S A A R C Iq
ENGINEER �u,.io ,i _-Vic CONTRACTOR ' Jk L /MI)Z t-Acl rl C.
INSPECTIONTYPE
INSPECTION REPOR.r
Jai -A I L .3 P4� q
40c se, A tj AJA 14, INJ G - CIL, m ASC 6 7 -C-
T 1kLy y t\ e, t1P Q
i2, `P k );A t:`7'e 1? 45 +1 d6 PVY IJA s
-T < L i - �)15 - ".7— PR iJ-GtZ P1 Y ltb I L I Cd P1 ;,,)I- e
t t-5 - W-5 -1 - :59c- al I?,, o -),b 1�J` Y NAi(...,J6 --
C. -rA I L it Aq f —1'4-'(Z
CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted
substantially complies with approved plans, specifications and appjicable sections of the building codes. This report covers
h% locations '6fihe work inspected only and does not constitute engineering opinion or project control.
Poe
CEFjt.No. INSPECTOR NAME
r
(Prihaearly)--
DATE -(0 ;�t" 3W INSPECTOR SIGNATUREC:124z'-"