0301-354 (RER),Ihereby affirm under penalty of perjury that I am licensed under provisions of
(3hapter 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
Date Signature of Contractor
OWNER -BUILDER DECLARATION
1 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).
( ,:) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). j
() I am exemp : under Section B&P.C.;for this reasb
Date `�)�" Signature of Owner..;.._
tir�
WORKER'S COMPENSATION DECLARATION
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:
Cartier 3ZATE pUAD Policy No. 04.01t,Nj'1'000141S
(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 Section �3 00 of the Labor
Code, I stpll forthwith comply with those provisions/' r
Date: J .,,,, <<J Applicantl...,.._.,..:r%t-,....� __....-
Y P
Warning: F ilure to secure Workers' Compensation overage is unlawfu�,nd
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 represen atives of this City to enter upon
the above-mentioned property for inspection rposes.
["Signature (Owner/Agentj"�w- I— • •-/1'F" Date - r
BUILDING PERMIT renPAII ff
6d
/
DATE ; _ VALUATION LOT TRACT
JOB SITE
ADDRESSi;�.tli�:�a£D �..ng�er�S*br3.., �i.i�i�,?i4g1i"'R
APN
OWNER
CONTRACTOR / ESIGNER / EN INEER
P I .• WE:;S°r"". ? EIT3I 1:,t L•,?4 �`2�i
�? 'I..P haft. .�! ?(�" C3'dtib �F+l:t" !! ' i�t!"T�:
P,0.BOX 1060
22531 u301T'i`T4
:jn:A:ttit,fl:1TTAi L::A 922151?
('.`.A:,rg.I:4:II"'Ei'.IXY'TYLE VA CA. 72001?
USE OF PERMIT
91.130. 16: 544R"in .4,. S5. VC1 11-1('.f f IZY
��.:�s:>if..t4A�1.-I:t�tik.� d•IrlgNft��>v'is Iry:t
INIUMMIXD COST OF (1101.4114TRUCYTOR
21910W00
CIOM1`j'1?,a;lC°i RAN Rx;'
STP MOTTOW Y&I - 3e.bSID 101 -•000 21'C -Civ;}
?[:FEEBO
3 2UU3
CITY OF LA QUINTA
FINANCE DEPT.
3��'i-.f?�:1',�'��..:{,:l'�:t:�i7^I.°,��iiC'��.Clk� .��n1!�%�.� .�.J...i;fl'3 {��k�' µ`•Vi,
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TOTAL V.E��v:tA.1i`J.'Jf'71y,`IS _(3UR TIDW
9."ti)-'�xv)
RECEIPT
DATE 1
BY
DATE FI
I P OR
:S
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Page of
DAVE STEAVENS
Inspection Services
PROJECT �3A U)r, STg L E %J Z PROJECT #' c;- UO 3 0 q
ADDRESSS Y- 899 943 CLIENT Ped uj,�r5-r Alm
�ItJG'JSc�fCacr�,J DATE
BLDG. PERMIT # ARCHITECTr3L
ENGINEER, am SAt o,E 7�Jc . CONTRACTOR�),Ci. / AX
M
INSPECTION TYPE
INSPECTIONREPORT - --
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7 - fs�uCa.��.ri L- lc�tS. �f�i- `l '5 IgU0
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all, of the reported work, unless otherwise noted,
A2 substantially complies with approved plans, specifications and applicable sections of the building codes. This report covers
00helocations of thii' rKinspected only and does not constitute engineering opinion or project control.
CERT. NO. C7i"3 J 3 54) INSPECTOR NAME ZA JC `-' f A VC��
(Print Clearly)
-DATE Y�f �� c�0 • � INSPECTOR SIGNATURE' ";•aA_06_
DAVE STEAVENS
Page of
Inspection Services
PROJECT�&A Wr.
PROJECT#
ADDRESS 693, gcI CLIENT Y-IGA
pi-4Jg DATE It AMIL aoo-3
BLDG. PERMIT #
ENGINEER Z.,jJ '6)Aoo,r-- �oc.
INSPECTIONTYPE
ARCHITECT C,OGS A A e
CONTRACTOR-Jt,L 0*1 Ail � c, ri c.
INSPECTION REPORT
Ak.-gs d/f. 1A 1t- 13 lt-C4< 14110 AC %'1 k,)A 6
- -I 1A I -I,- - -1 -
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7
CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwisei'noted,
Osubstantial complies with approved plans, specifications and applicable sections of the building codes. Thishreport covers
the locatio%.df thW%v inspected onlyand does not constitute engineering opinion or project control.
CERT. NO. Qa±5 4f 2?- 5�O INSPECTOR NAME
DATE INSPECTOR SIGNATURe�� 1409��
DAVE STEAVENS
Inspection Services
PROJECT;��A ilk T •CE6Cuc,5.
ADDRESSS''V-805:
8 39.403499'7
jlavtrauasi
aLl)&'
j4
r1.+J8.
BLDG. PERMIT #
ENGINEERZ u.,J 5AJo ,� • Tj c .
INSPECTION TYPE
x ,
Page of
I
PROJECT # 07 U4C;l 3 - U
CLIENT 1.& W e.-b'r' M o P,
DATE (0 IF ?k I L. deog S
ARCHITECT 604 6 if A ec-�4
CONTRACTOR e Z 01144 + Fe
INSPECTION REPORT
C't A 1 LS '- t 3 f s - i " &C-1 e-WiJ ! f4 •,;19 S �c1, t._ -r r --
AM U
A%f1rr.tc:'1 c,'
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i
F
CERTIFICATION OF COMP, UANCE: To the best of our knowledge, all of the reported work, unless otherwise noted, r`
substantiall omplies,with approved�plans, specifications and applicable sections of the building codes. This mport overs '
the locations of thework inspected only and does not constitute engineering opinion or project control.
x CERT. NO. Q S' i INSPECTOR NAME I p �e .x
+ f
DATE %p /r A0'L 104� INSPECTOR SIGNATURE . ''