0104-219 (BLDG)LICENSED CONTRACTOR DECLARATION
I -hereby affirm. under penalty of perjury that I am licensed under provisions of.
Chipter 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
73:31TId. ' 1i
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& ProfessionalsCode). .
( ) I, as owner of the±property, am'exclusively contracting with licensed
contractors to construct the project- (Sec. 7044, Business & Professionals
Code)..
O 1 am exempt under Section B&P.C. for this reason
Date ' "Signature of Owner
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 fog workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit -is issued.
t (,,) I have acid will, rtiaintajn'workers' compensation insurance; as.required by
Section 3700 of theLaborCode, for the performance.of the work for: which this
permit is issued. My workers' corripensation insurance carrier &.policy no. are:.
Carrier Policy No.
(This section need not be.completed if the permit valuation is for $100.00 or less).
O I certify that in the perfo'rr fiance of the work for which this permit is issued;
I shall not employ any, person it any,manner..so as to tiecome 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 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,attorrieys 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 PERMITq
DATE VALUATION LOT 0.104=4A9 TRACT
a:�ira?1t�19.ilti: " ;
JOB SITE
APN
ADDRESS
Ayp, 77 C
OWNER
CONTRACTOR / DESIGNER / EN (NEER
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I—A Q-0-1 4T..A. CRA 922.5.3
S(:;UAN,A:i3kAC H . CA `92075
(856)792-1.500 csi,� 58`3
.USE OF PERMIT',
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APA "2" 0 2001
CITY OF LA OUINTA
RECEIPTFINANCE E
BY
DATE FINALED
INSPECTOR
t Page of
x DAVE EA 'S"
` Insked6n Services
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CERTIFICATION OF COMPLIANCE To the best our knowledge,'alC of the reported work,' unless 'otherwise noted,
' Substantially complies with a.pp�oved plans; specifications and:appllcable sections of'the„building codes. This report covers
--Afie locations of'the work inspected hnl d does not constitute.engineertng:opinior 'or.profect control.
CERT. NO. �7�� T D 'SO INSPECTOR NAME `:I J
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DATE =1 .., its QI INSPECTOR SIGNATURE'(41
Page Z of
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DAV"ES-- T VEA S �.
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;.PROJECT ,� L�rS1�5 (A PROJECT'#
ADDRESS' CLIENTAyJEST t4 Opt
DATE
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. ENGINEER,16 y1 JAJ ocz S �L ` CONTRACTOR..VtL Al qe-
INSPECTIWYPE
INSPECTION' REPORT;
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CERTIFICATION OF COMPLIANCE To the best:of our knowledge, allof the reported work, unless•othenNise noted,
D6bstanti-allico'mp'II-Sw'ith"-pproved plans, specifications and applicablesections ofjthe building codes.•This report covers
he locations of the work inspected"only and does not;const�tute enginee�ing'opinion'or project co61trol
CERT. NO. 5 y, v 4 'INSPECTOR NAM 1 �Jt 5/4 !iElJS
DATE ..S C.t nJ, �:.. oZ'y'O f INSPECTOR SIGNATU , .
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Page Ll� of 3.
DAVEST. AVENS
hspections Services
PROJECT :-C NA SE" 1 A PROJECT #':...off
:.ADDRESS A S L IST � ;� . CLIENT t G R i.J Es.? 140,4
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CERTIFICATION Of= COMPCIANGE To the best of our knowledge, all:of the reported work,<unless otherwise noted,
ubstantially complies'with approved plans, specrfications and applicable sections of;the building. 60 report covers.
he locationsof the work inspected'only and does not constitute en"' eenng:opinion or project.control.
t.,r ...,... _
CERT. IVO. 08.593- 1NSPECTORNAME 1,. ���AJ��s
DATE /3 .71�,n"� e^i b7Q INSPECTOR SIGNATUt,IE J' CieaNl :
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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 buikiing,,codes. This report,covers
the locations of the work inspected :only and does`not constitute engineering opinion or project control.
CERT. NO. INSPECTOR NAME �'J'.� J'tEAt/E►.�S
NC. '�,
DATE f UINSPECTOR SIGNATU
.... �` • . . .. .... a ..t �.
Page L of
DAVE..
.,�: hlspectio Services
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PROJECTS �� S'C' b1�5e: �' _ ' PROJECT #
ADDRESS:S`'f y3 j 4a4 ..3'9"1 CLIENT Pe . W QST_ H V A
0 1►Ls-FGhoZ�D�h
BLDG. PERMIT # ARCHITECT 66424. C t-/ `
ENGINEER k,U . SA:I o f N CONTRACTOR�f L /1'1 �¢ 2
INSPECTION TYPE
INSPECTIONREPORT
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CERTIFICATION.OF COMPLIANCE: To the best of our knowledge, ali'of the reported work, unless otherwise, noted,
plies with approved,'plans, specifications and applicable'secticnsbf the`building'codes.'This report covers"Ssubstahtially,'orn
the locations -of -the work inspected only and'does not.constitute engineering opinion or project control.
CERT. NO. 06:5 3q6- Sy INSPECTOR NAME~' f Wy e ✓/ -A J E
( r nt Clearly)
DATE I�2C o?U..p I INSPECTOR SIGNATURE �`