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0301-356 (RER)U) U)04 W �. O Lr) „w C Z r` _JL) �afl - CA Z Co CV ON 0< Q o m Z r i-0 X W m< O C L0 Z_ c0 -3 r-0 J 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 Professionals Code, and my License is in full force and effect. License # . Lic. Class Exp. Date 7334,52, D IM", 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). ,j') I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business & Prpfessionals Code). () I am e mpt der Section B&P.C. or this o 'Date Z-. "n /r' ``� Sianature of Owner.___1 ',,/e o 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. 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.dz`1t)04601 Uh1I1'Q"4I$ (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 ' I should become subject to the Workers' compensation � rovisions of Se 4iO3700 of the Labor Code, I_sjI forthwith comply with th se provisi..ns; Date: %' ..� Applicant•�.� _ ... - ,.....,._.- .. "-. • r � Warning: Failure to secure Workers' Compensation coverage is unlWul 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 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 representati es of thirk.City to enter upon the above-mentioned property or Insp cfion GAoses. Signature (Owne,,Agerit)— r�" Date.Z. BUILDING PERMIT renmirtb + DATE LOT TRACT ; VALUATION $20,(=.f)0 JOB SITE ADDRESSis�i� �%�.6.t.9 h.Rl n7.�.7A5" JfS NA�iil.i..G n12(�.i� APN OWNER CONTRACTOR /.DESIGNER t EN INEER PGA WE'ST'r:F=.5F'.�o�3'fMT PSSN f:tR11:4 C(.)1qTR.W11J%A. R.Ws 1:J% P.O. pll.r ; 1060 ��i'3 � ��>i;f'.6 i3t C�Cy�� d':IFft'o}:uk�l�.1 `3_�'.I?., 250 L k QUY11i'. A C.!A 9223a; 9200 060)635.1010 01,214 58D USE OF PERMIT 13),M. 1& 54417, 34-8.ki, .M -94Q, 54.845. V Li:ra4'f.ARY *` R UCTC4k., L IkTCt��.IT�I�° T'i N U'.tt'T3C.rEd.I~� LS �'°��'4•�.1vhi•.t� �ry�i.lr.. •�i��.:twi[.f�'I�'.l �c. S'ITRONO MOTION YEF, RESiro 101-(M-.'141-000 FEB 0 3 1UU3 CITY OF LA QUINTA a FINANCE DEPT. - b lw';l'AM t:`1:';1,1 CM.Sj i '.W_ x.rss 1'irt.E'.. `�; i) lrr,Trm $0.00 ,./', 4.i+,I; ;i ,S.L ,S;.f.•�.IA.L'Y1..>!'.6'.�'!.Y,j,iC 9 D7. y qjR I:'�Ot"9.t yyW RECEIPT DATE ; J, 8 DATE Flj4ALUD IN E _ DAVE STEAVENS Inspection Services PROJECT ADDRESS BLDG. PERMIT # ENGINEER. 71 )C. INSPECTION TYPE Page of PROJECT # ePoo -3 — 0,9 CLIENT) DATE ARCHITECT q kC k1 CONTRACTOR4- PaoC i r iC. INSPECTION REPORT 3 / - ``7 p Bcry,"e Ar)/0 A4 AJA ioc7'A,L_5 - 41A 7 — A)4 AA/,8 Pa ,. (.o�., v R PL V A,/.4/ ) J 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 khe locations°of the work inspected only and does not constitute engineering opinion or project control. CERT. NO. INSPECTOR�NAME _ � Z 1t1 >`'� .7 -t/W A � � � %�' ��,�' " TOR SIGNATU(Print Clear DATE ty) INSPECRE...-� ri, �,� , es .�,-w+..,,.-y...ns^��Sctn�x.yw.,,v,...x.+r;-::.s�vr-.,."w�;r"�t'�', 'ri.� #•-L;�zx"Si!��•:r.ti:+;�'',C�. ,.., is':.::yy';y�'��;if �;jx� -. Page E of DAVE STEAVENS Inspection Services PROJECTP6A Gt.Jls_5"r- 4r6cAlo5. PROJECT # c?c03 -•QST ADDRESS T41 -13T17 CLIENT &,tI W E S"i 14DA "rc/y r`�,c1E'S 5 Pl-,41 17 ,1�c 1., 16 DATE BLDG. PERMIT # ARCHITECT �;OL,8 A ,<I1 CH ENGINEERlu');3 JAI_k>#C G CONTRACTORI\C� fnA,Z PA6t ;:''rC, INSPECTION TYPE INSPECTION REPORT r L 1, .3 5 7 -,J.�f Rd 464 5 - % .SNE—T-A I t-5 7'A7-tnfL-3s s L�� ti5 jus • ahc..a.. T►R t v h '�/ - .QCVC Kra) —00 A4 0 LE T.6 4 17 f 17 , / , r . 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 die locations`of _fi 'work inspected only and does not constitute engineering opinion or project control. CERT. NO. INSPECTOR NAME J )A c14C 5_7 � / 1/ 6 t5 © A r211 (Print Clearly) QO.... INSPECTOR SIGNATURET` �