0301-357 (RER)I hereby affirm under penalty of perjury that I am licensed under provisions of
F- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
LI, 01rofessionals Code, and my License Is in full force and effect,
O :5 M License # Lic. Class Exp. Date
I LU � ''::3.•31:'2 i=)1tC~ ar f t f°Ci
r
cOZ � Date Signature of Contractor
~ OWNER -BUILDER DECLARATION
J
W LU
~ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
CL
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).
C/'} I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business &, Professionals
Code). r/ I ' �` /
� O I am a emp under Section B&P.C. fot this re so)/
0 N Date Y.f6�.T^r `> Signature of Owner..-.
- r
CL Q WORKER'S COMPENSATION DECLARATION
o IX I hereby affirm under penalty of perjury one of the following declarations:
U') H 0 () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
0J QJ performance of the work for which this permit is issued.
co Q U (,. ) I have and will maintain workers' compensation insurance, as required by
0 U Q Section 3700 of the Labor Code, for the performance of the work for which this
IlLO1- permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carver :3T,ATF, FUN!) Policy No. NCO) lJN11110090 v
ao -)
C7 -
• 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 V should become
3 subject to the workers' compensation provisions of; Sec/tlory3700 of the Labor
Code, I sh,�l f `rthvwith comply with those Zprovisiop.s;_,_
/;. Date: , �, " Applicant
a
Warnin : F ilure to secure Workers' Compelation coverage is unla%6) 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 c
the above-mentioned property for insp ction.puy�oses.
g
g
Sinature (Owner/Aent)._
�.. "�.
BUILDING PERMIT renmii rr
/
DATE / % VALUATION LOT TRACT
JOB SITE ADDRESS .w';i.�eI.a 1.IS", L��.(:e�.WW- iTNTE�irKE'S
APN »..
OWNER
CONTRACTOR/DESIGNER/EN &NEER
A3".l`Q. fMl i'MI"T-Ctt?:oNTIA.t AMA
d. EL,MAk PAF 1140
11 0_130,x 1060
Vir143 Lei rWI]25(1)
7.AQi:.i1.K)TA 9225?
CA 92,007
USE OF PERMIT
,ryRYTERAI,
19: .",r"t, M f, 4 011,010.f R 1j
h+'i t�l.lE :'1' 1F(�tl 1.: 1�1•C?t".ii f�IC•�,�' YC..,�( .
i/AIXA.'2'trON LZ
3: �,1�'.IamArm 4"or :l wr
101
fa'i'1;'l:f•Yp�C6 ttR(7'I"f�:l� frk�� • i�.t',c�:tli 1f.�iwGfla�•Z�Y..{)fsCi M'l.t}ZF
Iv
FEg 0 3 ZUU3
CIVOF QUINTA
PINANCE gepT.
'RT 11("'f N.114Y1•%
T01AL Fh°j;:1:2`t1.'f: l':9+I;7F.?.8 P 0 E 140W*
RECEIPT
DATE f
BY^'
DATE F AL
INSPE R
!-.
D
A I
DAVE STEAVENS
Inspection Services
PROJEL-T Pr -A Q C !—i GC ,JO 5
ADDRESS 5q,-8y1r e3pit S3'. SAR
-t ,JEss X -4i 17
BLDG. PERMIT #
ENGINEER SA '&-) u -'nc
INSPECTION TYPE
Page of
PROJECT # o coo 3 - a S
CLIENT _ ?t A t,Jt s T 140A
DATE 4:, 01A y e; vco -4
ARCHITECT Go L a A A R O.4
CONTRACTOR le- L IY A iZ 1`'f cf cl L
INSPECTION REPORT
L'S
- 1. 3 I S` 7- &.0C k AJ 4 PL `/
A A t,C wl a-y,M DG E r
��^c'a`�'S
" Uyt� iS-`i - r�,iY�r kl��.c /�r-t�-T�,?3
s'�✓f1
�CY /VA,Lr,�1� `Ua•,�Gt"�"�-�
�I "' `�-A � � S "
•��'?`S�'`�" �A i T'�,t G £t)c. �`�l i�� �.J rl
�C �
�J
N� � t. i,JG - ��+tit s�GC �"ax -• �
r
6- i - 5 fel;: b it 12A r i "t,2 S �t rJ ti
i`�l
t' _
Y OtIA r�c-
.
f
�� TA ► C.S -
r 71s • 7 � Sic: X12 � 1�h F~rc:•rz ,t�Jy
�L y
�1� ��r,J�.- ��M�cG r�
r • �r
CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
�ybatantially complies with approved plans, specifications and applicable sections of the building codes. This report covers
e locationsWhe work inspected only and does not constitute engineering opinion or project control.
~ CERT. N0. J 7 t7 �C•%
DATE ih A `�(% O 3
INSPECTOR NAME
INSPECTORSIGNATUR r24,,
4
�E�r a+mss • %-- - -
{
1771 7 -
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 ofthe building codes. This report cotrers
e locations of th rWbfk inspected only, and does not constitute engineering opihiion or project control.
e • I ./. - ' tom:.
CERT. No. INSPECTOR NAME . ' A sL� ! G AJ605
SATE ' INSPECTOR SIGNA
. , ° ( �3
41
DAVE. STEAVENS
Page of
;
...�
Inspection Services -.
t
PROJECT S A � SY
-LEL �J.t1 PROJECT #
cPp o 1- 0 (4
ADDRESSSSI=icy{ �3�t'
933.1 Sol 9 CLIENT t)C„A
'X44CA&GS S -{tic ArJ/7
&&& 14 DATE. S
Inn `f 4yo.3
BLDG. PERMIT #
ARCHITECT
»O I- 404 A R C H
ENGINEERS k&-j,J
CONTRACTOR �rr L *f A iZ PA E.r'7e.
INSPECTION TYPE
INSPECTION REPORT
s
�t rA E t. S Yd As -1 -
L -1,0 s AIA ► t -W [� . - C (O n, D L e7'eg'
�E�r a+mss • %-- - -
{
1771 7 -
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 ofthe building codes. This report cotrers
e locations of th rWbfk inspected only, and does not constitute engineering opihiion or project control.
e • I ./. - ' tom:.
CERT. No. INSPECTOR NAME . ' A sL� ! G AJ605
SATE ' INSPECTOR SIGNA
. , ° ( �3