0208-082 (RR)LICENSED CONTRACTOR DECLARATION
1 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
N W Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
o(3 LO 235717 C-39 B HIC 01/31/2(
W
r- ~
~o Z r- Date Signature of Contractor
O11�
1— CD OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ CL
W 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).
LO () I am exempt under Section , B&P.C. for this reason
N
Date Signature of Owner
O�
a Q WORKER'S COMPENSATION DECLARATION
0 cc I hereby affirm under penalty of perjury one of the following declarations:
O () 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
O J Q performance of the work for which this permit is issued.
Q U ( ) 1 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
LO H permit is issued. My workers' compensation insurance carrier & policy no. are:
`t Z Carrier STATE FUND Policy No. 0457624-02
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(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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful 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 inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMI0208-0$2
DATE VALUATION $20,418.00 LOT TRACT
JOB SITE
A SS BLDG. 7 INVER�'VESS
APN - -
OWNER
CONTRACTOR/DESIGNER/ENGINEER
PGA WEST RESIDENTIAL 1101VI.-OWNER'S
kScl WESTERN PACIFIC ROOFING
PO BOX 1060
3462 LA CPIaAITA WAY
LAQUINT A CA 92253
PALIVI SPRINGIS CA 922062
(760)416-5377 CBL4 4293
USE OF PERMIT
GENERAL BUILDING
B DG.7; 54.901, 54-919, 54.937, -955: RE•ROOF WITH
POLYURETHANE FOAM &ACRYLIC COAT INS# ROOFING SYSTEM
VALUATION 20,413.00 LS
ESTIMATED COST OF CONSTRUCTION
20,413,00
PES I' FEE SUAlAfT RY
:REROOF FEE 101-000-418-000 $30.00
SUr3-TOT-AL CONSTRUC 11ON AND PLS.1 C=CK
$30.00
LESS PIZE-PAID F—EEN
$0.00
TOTAL PER -AM M FEES DUE NOW
$30,00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
Page I of
�3 DAVE STEAVENS
Inspection Services
Q
PROJECTy7 t�i- L C. G E S PROJECT # foo I- a 3
ADDRESS As t t tmc'\l CLIENT P G#k. WJE 5; N0,4,
BLDG. PERNUT #
ENGINEER -i tAu t,) 5A \)o i C \ ,-,s c --
INSPECTION TYPE
DATE t "ot 5 E p i 0-0c) 1
ARCHITECT GOL:i6ii
CONTRACTOR"*�4t, ' M Ar2..
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
Usubstantially complies with approved plans, specifications and applicable sections of the building codes. This report covers
he locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. NO. O g 4 .3 g-� V INSPECTOR NAME C I t.Z 4
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�� DATE I a SC, t'� � 07 J O / INSPECTOR SIGNATUR
Page i of
DAVE STEAVENS
Inspection Services,
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PROJECT-�(-,4s" WtLs-i- PROJECT # ova / - 0 9t
ADDRESS -A 5 CLIENT -?G'A We S 7- too A
BLDG. PERMIT #
ENGINEER kQQI E. 1►JC .
INSPECTION TYPE
DATE _k
ARCHITECT Go (-% � f6,ZC-),% I t c-rU-aE
CONTRACTOR7t,L AN fhZ - pNc --(C.
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
substantially complies with approved plans, specifications and applicable sections of the building codes. This report covers
\,�e locations of the work inspected only and does riot constitute engineering opinion or project control.
CERT NO.O S�7 .� ' .T U INSPECTOR NAMEEA VC WS
DATE �� S C �% v� 00% rim Ciearty)
INSPECTOR SIGNATU�C�-��2