0104-217 (BLDG)LICENSED CONTRACTOR DECLARATION
U) 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
04 W P',ofessionals Code, and my License is in full force and effect.
O M License # Lic. Class Exp. Date
CY LOW
oZ r— Date Signature of Contractor
0_ �
P:Hc6o OWNER -BUILDER DECLARATION
J
HaW ~ 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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
cr) () I am exempt under Section , B&P.C. for this reason
U')
N Date Signature of Owner _
ON
CA
a- Q WORKER'S COMPENSATION DECLARATION
p Ir I hereby affirm under penalty of perjury one of the following declarations:
Lo FQ- O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W LL compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q I have and will maintain workers' compensation insurance, as required by
Q U Section 3700 of the Labor Code, for the performance of the work for which this
0 permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
co 5 !.`Ai,!tJi:;;r:h9;rICY 12:i!r��l')�,t,
�a
J (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
1 subject to the workers' compensation provisions of Section 3700 of the Labor
r� Code, I shall forthwith comply with those provisions.
Date: Applicant.
1b Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fine3 up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE VALUATION
LOT 0104 -:21 -i TRACT
.'r�tl, OY.1.()tl
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN (NEER
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i..!A r12;153
:3t.tL.l01 kBy V.1 CA 92075
jty,".i',1r!)2 }3()�► C'SiL,�1 5823
USE OF PERMIT
t CJf.'.fR1, 00+10? I'NI^:)R$e[It't'K')N
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i%i:/Et0 M-L''O'f` OA 1"T! Le,
Ilol-o'o01,41-1400 $2.00
.i'Ttf-.s-l'.F)XG }17.01-111
$0.0')
CITY 4F LA (1UINTA
FINANCE DEPT
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
1
DAVE STEAVENS
Inspection Services
PROJECT 1�.,�AS� IA PROJECT #
ADDRESS A -5 (rr 5-rcJ)
Page CA of oZ
CLIENT t QA wE $T H06
DATE "T S'Lc C c-;� v -o I
BLDG. PERMIT # ARCHITECT _Got --.94 4t'?r-c t, r cruR-c
ENGINEEI��t)u,�,l J o «. - r.] G CONTRACTOR "Je L rn,4 K
INSPECTION TYPE
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
�f'the locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. NO.n- 7 -3 4 �- 5 6 INSPECTOR NAME � a V Z �!4 i%4i S
t y
DATE i�3V-►.lt :L O c� I INSPECTOR SIGNATUFM
_�
DAVE STEAVENS Page of
0 Inspection Services
PROJECT �r,A QZ'57 — 1 Ft PROJECT # 62 vol o
ADDRESS A S tf- D
3Lb - tr
BLDG. PERMIT #
ENGINEER �,j,i S ,s v T oc_
INSPECTION TYPE
CLIEN ( _S— 140A
DATE to 7"u Q E .7-001
ARCHITECT GoL-3 A A2w e rnaT u a o,
CONTRACTOR ` !�7L my\ sz A i- r L
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
``pubstantially complies with approved plans, specifications and applicable sections of the building codes. This report covers
,.,fthe locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. NO. - 5 INSPECTOR NAME
(Print Crty)
DATA -�� ti1 C �C� 0 INSPECTOPI SIGNATURE ��.-.�
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DAVE STEAVENS Page of
Inspection Services
PROJECT A - s 5L PROJECT # o2CX0 C — 0 3
ADDRESS -A
BLDG. PERMIT #
ENGINEER1 ,a A 1 e. r t, -
INSPECTION TYPE
CLIENT -
DATE i E a cid l
ARCHITECTr-) o t.3 A F�QCA,T CT►� k C
CONTRACTORJ�,L M AR _ Ncl r[ G
INSPECTION REPORT
41
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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
the locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. NO. INSPECTOR NAME
IBarly]
DALE t [] d INSPECTOR SIGNATURE 'fb_�•�
�
DAVE STEAVENS Page of
Inspection Services
PROJECT -i%PROJECT #
ADDRESS A - i i c
BLDG. PERMIT #
ENGINEER -') S A'J o I r'. t o c -
INSPECTION TYPE �E Po yd
CLIENT
DATE � O M A -t a coo i
ARCHITECT C�,oL,°6A
CONTRACTOR � L -
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
the locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. NO. c tib
C� ' Z� V
?LA►J
-Ttrg J F, JS
i1y)DALE
,�,Ca
�'�at1 �i
INSPECTOR SIGNATURE
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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
the locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. NO. c tib
C� ' Z� V
INSPECTOR NAME
-Ttrg J F, JS
i1y)DALE
,�,Ca
�'�at1 �i
INSPECTOR SIGNATURE
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