0301-357 (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
C14w,: P}ofessionals Code, and my License is in full force and effect.
C License # Lic. Class Exp. Date
W ?'3 :3r;i'! G!:}
cZO � Date Signature of Contractor
J UOWNER-BUILDER DECLARATION
HUJ r I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) 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).
6(') I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business &, Professionals
Code). ' /
Cf)O I am a emLIDp under Section B&P.C. f4T this re so
O N Date : f�� �T. � Signature of Owner.. .m:+!••,.._-+ 'r--,` �•-
U /
IL Q WORKER'S COMPENSATION DECLARATION
p cc I hereby affirm under penalty of perjury one of the following declarations:
LO H 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
0O _ Q performance of the work for which this permit is issued.
Q U ( 1 have and will maintain workers' compensation insurance, as required by
O U ic Section 3700 of the Labor Code, for the performance of the work for which this
d rn F- permit is issued. My workers' compensation insurance carrier & policy no. are:
eo Z Carrier :''1',f TE,, I�`UNT) Policy No. U�f60) k{.N1'!'VP094J
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 thpt ifA should become
subject to the workers' compensation provisions of, Se�lo 3700 of the Labor
Code, I sh II f `rthfn/ith comply with thosejprovision.9 ,•.
Date: �l } `'" Applicant __ �' - -c
Warnin : F ilure to secure Workers' Compe i ation coverage is unla%W 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
�rV�ip & 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 inspg6tionpuy{ioses. i•
�,. Signature (Owner/Ageno....••"1�' Date, I
BUILDING PERMIT rcnmi rr
�LZ
DATE / VALUATION LOT TRACT
JOB SITE ADDRESS 1'1.�.I.lf 1. 91L.:1,ta'�:.�{.�1Si; - HTV.i��s'.Nf.S5 �iU
APN
OWNER
CONTRACTOR/DESIGNER/EN &NEER
P 1,JA EKf" R.�',:Z4'7i iFtld .TIA1.., .ASSN
1)P L .c+KA,4i PACIFIC G�.�3'TTRAL f `C►x+f'1. L1NL _ J`t.1y
+w ro n -v
1.,A!�!'1�R is L.,t�L ��� � J �
LA
n �. r
1_.��5�_C 3�7, � if � � ��L: P� i�1 CIA 1200'1
USE OF PERMIT
(:1F131DQLJ_
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t' i)l tl'l 12t1 '• '!t` ani FIV IM -CM -M-000 =. $Ar .
:p�'Xt.C.S'1+�`C€14Ri:t'F'iC)Ert�f+;:�-3t�:t[;i 1�.��-�E1C)l1•:l�lf-{I4t:i �'d.(),a
FEB
CIT( OF LAQ�INtA
FIN CE SEPT
;if jl:'e•.`[L.°f';i'if.. �`fY �3 T f'I?'E7'r,'>'a' yid'.(�1 A ' .�(1i`! CH"04-'k;,
.N -IN C+°YE.`Eiy
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RECE:PT7EtDA�
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DATE F AL
INSPE R-:17
14
110
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PROJECT PK A O c i - L e Gc ,J a 5
ADDRESS 1 3?7,82Ck
aJ�,zfJESs PiA,J 11. c�c y 1`4
STEAVENS
ks -Inspection Services
BLDG. PERMIT # .
ENGINEER
INSPECTION TYPE
Page of
• 3
PROJECT # 0000 3 - y ('
-t
CLIENT' tic—.r HOA
DATE `nA y a vo 3
ARCHITECT 6=o LcaA A RCP4
CONTRACTOR 1E L MA i?
INSPECTION REPORT
J�TiAILS- I+ 3 t`�LIiC�! i4,c1cJL4/ ltJAr�or:1 G - t�OcET
i to 1 iN r�� �i-1 i- T � ,z 5 f� �✓f1 7``1 y /)A � � , ,J G ' `y � w� C.r re
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_10rA►L5- f7/6--2 59,tlrt ,ado ;4-1 A)a1LIAA;-- CIO e"f)cC:r4
CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
ubstantially complies with approved plans, specifications and applicable sections of the building codes. This report covers
e locations`ofihe work inspected only and does not constitute engineering opinion or project control.
CERT NQ INSPECTOR NAME
`-DATE � � � `� �J � � y. INSPECTOR SIGNATUREQ:0rIGzf'.. ��•:x. r.,�,f`-":.:•
DAVE STEAVENS
f Inspection Services
PROJECT % A W g s'c - LC (.'6:_ lao 4
ADDRESS 54/ tQy1 3'1� Sa 1
:rwd,eUesS A.AJ/7 J?W" 9
BLDG. PERMIT #
ENGINEER_14,J rJ S A J 0 � � ",✓c.
Page % of
PROJECT # d00 3 — O
CLIENT "�(:�. A Q e S N M o Pt
` DATE $" InAY .2vo3
ARCHITECT Cao C 8A A R C H
CONTRACTOR )>C. (r M A ►c
INSPECTION TYPE
INSPECTION REPORT
1.3 LS - '7 - SCo-C)41 e, 4.3v'5'- Cvr►►Jc_C Tc
L • cr 3
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s - Q. - 7� , - �'u►� DL e T
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s
4
f
CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted, f
/-, Y P PP P P PP A
substantial) complies with approved plans, specifications and applicable sections the building codes. This report -covers
t he locations of thg--Wdfk inspected only and does not constitute engineering opinion or project control. >
CERT. NO. O INSPECTOR NAME '' L L) C;
'DATE IVY ;L OO<�.,: l �►N)
INSPECTOR SIGNAAR .�