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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
Pi,ofessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
770940 R C39 1W 11!30/01
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I 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). '
O I am axe u der Section ,yB&P.C. fr,(,�� s r of
Date _� <' G Signature of Owner ,�•�(!:% /; t'
I.
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.
r () 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:
Carrier Policy No.
STATE FUtdD 3800 p1997
(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 3700 of the Labor
Code, I shat forth ith comply with those p vrsro s.
Date: 1Applicant l 7`"14�
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 pefson at
whose request and for whose benefit work is performed under or pursuant to
any permit Issued as a result of this application 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 haf.ve 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 i9spection purpos
..r`. rSignature (OwnedAgent) —' 1 Date
I
DATE. VALUATION LOT 01WI39 TRACT
Sloan=,
JOB SITE '
A -i
ADDRESS ,o_ / J AAK R %
o
OWNER
CONTRACTOR / DESIGNER I EN (NEER+,
t
PGA•�W//'�Fygi I�EIR F���'
DGRAW. WC.
/��UTd33'I"W,
PA). BOX 1 N o
a �y� �R�0�M
83-59 f CiNf11e�[� ff.
LA QiTWA
DMIO ; CA 92201
Q60)347.9N CEW 5978
USE OF PERMIT
ii wtmV WITH CLAW A MATIPAULs. Bim 9: 80:80"1, 80601, �
>ZO.59�, t�t.559
VALUATION 1,504.00 LIQ
1 M C06r OF CONFATC113'I1f01V
2,�i10►.AO
>"ER�iiCI'Irm olum 1•ARYJ
}EROOF "I 10) -.00OA 18.000 :30,00
•7
`4
SEP 18 2001
CITY OF LA QW. TA
FINANCE D,- ,
1
MM -TOTAL CONWRI[IC170H .RM PLAN f
1$30.04
ILMM PR FAtD
$0.00
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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Inspection Services
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DATE 21
ARCHITECT CGb CAA X41-C� 4 r'� CT ucLF_
CONTRACTOR;bgz- 0M A /Z & ct Fi c -
INSPECTION REPORT
CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported
substantially complies with approved plans; specifications and applicable sections of t
the locations of the work inspected only and does not constitute.engineering opinion e
INSPECTOR
DATE( A u / INSPECTOR SIM
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported
substantially complies with approved plans; specifications and applicable sections of t
the locations of the work inspected only and does not constitute.engineering opinion e
INSPECTOR
DATE( A u / INSPECTOR SIM
A,, unless otherwise noted,
building codes. This report covers
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Page 2- of
DAVE STEAVENS
Inspection Services
PROJECT (k, PROJECT # OZ
ADDRESS 5?D-Sg . 59 5. (,ot Gu -7 CLIENT �6,
DATE (6
BLDG. PERMIT #
ENGINEER��y�.1
INSPECTION TYPE
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
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Jhe locations of the work inspected only and does not constitute engineering opinion or project control.
CERT NO. 0ef-93 76 - S L7 INSPECTOR NAMEJL
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ADDRESS { ' : I .r 7 CLIENT �G A 4 o R
DATE _ 13
BLDG. PERMIT #
ENGINEER�LL.�A1
INSPECTION TYPE
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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
+he locations of the work inspected only and does- not constitute engineering opinion or project control.
CERT. NO. �� 7 Ta S C� INSPECTOR NAME -C
(Print Cleary)
DATEI �U-(:L601 INSPECTOR SIGN ATU
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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 reportcovers
.the locations of the work inspected only and does not constitute engineering opinion or project control.
CERT IYO.,3 �` S-40INSPECTOR NAME t I 4- �1r�1 S
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