0301-374 (SPIN)I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
WProfessionals Code, and my License is in full force and effect.
6 =) C) License # Lic. Class Exp. Date
oZ ti Date Signature of Contractor
0
C) CID OWNER -BUILDER DECLARATION
W WW 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
t ontractors to construct the project (Sec. 7044, Business & Professionals
Code). Ir
N () Ism xq*t under Section B&P.C.1or this.reaso i ,L
O N Date ' "' ' "' Signature of Ownerf-
rn
CL Q WORKER'S COMPENSATION DECLARATION
o IM I hereby affirm under penalty of perjury one of the following declarations:
U-) 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
Om _ Q performance of the work for which this permit is issued.
Q()) 1 have and will maintain workers' compensation insurance, as required by
O U Q ectlon 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:
eo 5 I Carrier ; 'a', ,`! �` igjN- ? Policy No. W601 YT:f- YITAL'OIW>
�CY
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 shoyfd become
subject toltha workers' compensation provislaris of Section 3700,of the Labor
Code,.11s"ll fgrthwith 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 160 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) Vate
,BUILDING PERMIT r°"M
(1X.tI , I `
DATE VALUATION f LOT TRACT
JOB SITE
ADDRESS 1 �,j5#'u,k:. .w1.l�e ..l 1�S,. r"` �l���:)Jl.e.l�:17.',f+.At'a."% � 4
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
1a�=1's',.L�1:M1ik'��f.iril.l.).�J:1\'+LlE:<•. .ui.`i.l�
i' .. ;Mr i, `r j.�'
I.A �_(l�'1. /v'r'F. 92.25.,',
.i" 1'.1:I1i` C"_A. .'4 ?
USE OF PERMIT
;:,, ;_)�. i'1: '4t"s�f1�#5. �:•rra�J.';6�i).i;', �(i-f;,r(F '�r+�st�i.11�'P�::::.1"
ry J>.1:IJd't,V C) t. � �fStKs.. rill 1 -ii
°g'Y1-f—I•'I�:�a�I'
wrr,i)+�?x.f' ?
r014fi'j')<pj.."7'.1i.,)"ri;'FE ?(1�sj
H 1bT013+,'2c 'KXV 3 ES'11) 101•tt(ifl-2A I _t"D o 00
G til
FEB 0 3 7003,E
CITY OF LA QUINTA
FINANCE DEPT.
,i3.1•' ,:.t.,`^�t.>f� fy` 7: cr be'"';"il';4J 1' ' !��i`.; L':C +,("j:'�
I ,
RECEIPT
DATE.
BY
DATE ❑ INSPr
+ .f
11
Page of
DAVE STEAVENS
Inspection Services
PROJECT4 i:, t.li`"� + ' L rrC.n it.r5 5. PROJECT # o�oc-:= 3 (�
ADDRESS 36 •Ooy. 0, t2- c.)Ag d 3L.
BLDG. PERMIT #
ENGINEER ,�, ,,.� f A Jy,E" ��c
INSPECTION TYPE
CLIENT tit; A y,c..?C.5 f /-lvrfi
DATE `7 ll rV J L A uo
ARCHITECTS G+ A A W C 0
CONTRACTORPAf
INSPECTION REPORT
7�4t.,. ' L..P-r' r„1 Z j - �.. �
t
' `. i ra. 4 ar..`+a �~ / `� ` � _'s � � 4= � � C_t� r.. t.,i� � t l� t c_ a � � G. �. �- � •i°..+ � f;' � yin ,'.�L t: i i
r.-% N �
6, 5 - `? /^t
s r �
t,. / es/(» "
4 .-i A f J i.%
T O
.,,� t 1 to - ! t s 7 . 1. C61 r- A.,
1 1
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.
INSPECTOR NAME.+
(Print Clearly) ,
DATE / r"( �'�`i ': ��' ��i INSPECTOR SIGNATURE._"J ._ctS� c.-tx.. .,•h .�
Page of
DAVE STEAVENS
Inspection Services
PROJECT - (,A Ldcs' !_wt: PROJECT CP 4�1 4
ADDRESS.",.,oto.o;Z,4,tL):Sto CLIENT i - e -.A t-oc:Sr- WLA
-P':(.;o DATE P' 63
BLDG. PERMIT # ARCHITECT AtOti,-1
ENGINEER'-N-Q'SA do(�f CONTRACTOR D,, -'L IP)1-41
INSPECTION TYPE
INSPECTION REPORT
- -7 - L'4.oe WA All I') i"'6 `1 A.JA /4- " A) ('1 —
J)- PN t L
5 "k
— / - -7 - Kl- e-) r &.-' of ),� 1JL,4 AIX ,i t,J C- -- :"T E'-
4, , Pell '7-C ' 2 A sio "�'4 y A,1,4 I' e -
i A I L
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. ef") INSPECTOR NAME J 'A,J t L 4!1 'All-�
(Print Clearly)
DATE INSPECTOR SIGNATURE