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0301-358 (RER)Cl) 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 04 W Professionals Code, and my License is in full force and effect. O =) ch License # Lic. Class Exp. Date ti LU LO 3,3115,2 B :SIC° 03/' 91 /Z"' cZ � Date Signature of Contractor O� F— OWNER -BUILDER DECLARATION LU W I hereby affirm under penalty of perjury that I am exempt from the Contractor's ~ CD 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). cY) () I am ex mpt fider Section B&P•C. f`or this reason LO N Date i -"' Signature of Owner �•� . -m:- U N Q WORKER'S COMPENSATION DECLARATION C) � I hereby affirm under penalty of perjury one of the following declarations: Lo H p () 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 � Q performance of the work for which this permit is issued. CO Q I have and will maintain workers' coni , U .." compensation insuranceas required by p U Q Section 3700 of the Labor Code, for the performance of the work for which this D.: rn F< permit is issued. My workers' compensation insurance carrier & policy no. are: cb z Carrier c, 2'11'1?• k't3': t3 Policy No. !3►dt?9 f Tia t ) 00:,41413 r` 0 g (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 ffiould become subject to the workers' compensation provisions of �ectlOoK !00 of the Labor 3 Code, Fph Il fofthwith comply with tho a provisions - Date: `� Applicant` ' r provisions - ., Warning: Failure to secure Workers' Compensation coverage Is unlawf6Vand 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 Quanta, Its officers, agents and employees. 2. Any permit Issued as a result of this application becomes null and Vold 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 auth raze represents Ves of this City to enter upon the above-mentioned property Jor inspectio p rposes, Signature (Owner/AgeDate - BUILDING PERMIT renninff 's -3S DATE VALUATION QQ 2my'� �((.ee����`` o(yo/� LOT TRACT .. -t.. :if4'•Vy{,Pli6{Q.'I.YiI l 'r < ' JOB SITE ADDRESS P M. TNq APN }>; OWNER CONTRACTOR / DESIGNER / EN INEER .PGA WEST REVEDMTMA f., .AMN P AL"I C! G"R. N. MR, d C0N i'1:YW1T.,0 Y, , 1_31 5: X3: )C6U 12M) 1A q IW-YA C A. 92x,3.3 {"ACJ'}�,� �u` �r i°T�►.�' ��: A t t, a r, c C 1`y (mo.)os-1030 t:".(=fTA, 5823 USE OF PERMIT S�uL7�J)0; ) ;)34-tt'11:4, 3{�'i'-921 5A,S13. ' OLI::,a'6'ARY 6545�4)`7; F71 �.R.)b"�t•�.�6_iha (r ���A.�ji'S�n.T]. d'�l�J�lE7 ft:fa'7f;i.iMA,'kED C.Q., r OF ei:)fflY1M11X'1, 'I0X °'zo,f3w,m) r.� , �14t�.� 1"ti�J b S i4�ttl .f ��.F.• i 4/ -000-418-000 $20,31. 00 ri;.r.YA;c:t mC+,"ICYW FEE < RESID '101 1 -Ci 0-.26 f.1..0 10 FEB 0 3 1003 'v CITY OF LA QUINTA FINANCE _ DEPT. x'1713-� �=:i�_ �, �';U1�'�d'i�'p.3cw!'�.c•�+.iv� ��,i�'L'> T•�J`.P-�1;!' i.p:tT��a� `�:yi���.ufi "X' 1r G, :► : wS I7.'1' +" ;: , 1�1 f 6 ; !�!'C) B'ir s:1.@xi3,q* RECEIPT DATE DATE FI E INS CT .SIJ', ` 1 .....• �� DAVE STEAVENS Inspection Services PROJECT kN WiLS—i'. TtJUC,(*0L� d:nca ,..-C, BLDG. PERMITW ENGINEER 0 SiWo,4;- :,�T C. INSPECTION TYPE INSPECTION REPORT Page ' g I of PROJECT# .Poo s v CLIENT �6- A DATE 9 —itl-A,( ARCHITECT CoLigA CONTRACTOR p 6)".7,4kaere -, FJAL.L- --7 7 3, .x f\ 15 IA),Al,.L yl")o A j O jet, - C-Ilvl-i CERTIFICATION OF COMPLIANCE: To the best of our knowledge; all of the reported work, unless otherwise noted, *Wubstantially complies with approved plans, specifications and applicable sections of the building codes. This report covers e locati6ns of the work inspected only and does not constitute engineering opinion or project control. CERTNO. INSPECTOR NAME K(Print Cleaoy)--. TOR SIGN INSPEC ATURE DATE ;DA T VES EAVENS Inspection Services Page of f PROJECT �&A ue sT Lr_ Coed©s PROJECT #-- c�-00 3 - o q � ADDRESS e:2 (,4; / -70 CLIENT _tC, A W a Si 00A f ?'.1. c1 C r?,c ess A&.. '� D 4 AJ J3DATE � 0404 Y c�Ut7 3 2 BLDG. PERMIT # ARCHITECT 60LOP A,4iCl- i ENGINEER IU..00 - 3C AJa -rE J. c CONTRACTOR beL. NA AHC f F'r t INSPECTION TYPE I � i - INSPECTION REPORT ETAILS - E. 3 -7 scaiau.3S dA fc.�� 1� C0*1 e� Si A, re LG . sr CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwisenoted, substantially complies with approved plans, specifications and applicable sections of the building codes. This re - rt covers 1.0 the locationt6f1he work inspected only and does not constitute engineering opinion or project control. CERT. NO.� -•:� ��� I ����' -- .INSPECTOR NAME_ �/�..A(fL�-�� E DATE S of Y Aya l INSPECTOR SIGNATU� �, ,..-9�a