0301-355 (RER)U) I hereby affirm under penalty of perjury that I am licensed under provisions of
F— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N r „ w Professionals Code, and my License is in full force and effect.
O S M License # Lic. Class Exp. Date
oZ r- Date Signature of Contractor
(D 0-
J U CID OWNER -BUILDER DECLARATION
W W 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).
(u) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
Cf)
(.) I aro,e (eml i under Section B&P.C. fpr this reasc}n
O N 'Date •= {� ' Signature of Owner••---~_fA�/� °=
c � y
CL Q WORKER'S COMPENSATION DECLARATION
p cr I hereby affirm under penalty of perjury one of the following declarations:
Lo H 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
O � Qperformance of the work for which this permit is issued.
m Q L) y')' I have and will maintain workers' compensation insurance, as required by
OQ Section 3700 of the Labor Code, for the performance of the work for which this
IlLO 0)H permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z
co Z Carrier s T.A'g•E ;E•°EMD Policy No. 04601 UI°i"90034B
t` C�
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 1/�hould become
subject to1he workers' compensation p ovisions of,,Secti91i?700 of the Labor
3 Code;•4 111 f �.ith comply with tho b provisio s', ,
Date: �' = Applicant...;....:,..
Warning: Failure to secure Workers' Compensation coverage is unla ul 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 representatives of this City to enter upon
the above-mentioned property/for inspection` poses. ,
i
Signature (Owner/Agent) "� ✓`% Date
BUILDING PERMIT
Ily, <-
DATE ! VALUATION LOT TRACT
JOB SITE /7
ADDRESS�L,�a.
APN
OWNER
CONTRACTOR /DESIGNER / EN INEER
:��G:Y.%•�at.� ��� �r�������st'i'�.�4T .E?, �°�
;%J:��, •�!�1a�a .�':t�,f.'�jr„ �:b�il ��19=1.,1:E�°I.':ra'�?r^,i:'�'x,i.
(`Tait?:1�1?v�..�fiaGf f:.E3�l�s� tisMA;
USE OF PERMIT
(MM'AL efU111104(1
V1.00, 17. �A4' ',�, 544e.i 54-869,54.365. VOL,UNTARY
.ffEt.tfCTttRAJ MOD.IM",k°t'IONS
V A-11(a'ATH1111 41400100 I.13
ENR.1LhYlk"! D i a"3' "e +' �:"•L7:f 'i tl ;I:t "� tl'
t:3,(9t: 1.a:1t9
P`a:N3'.r'Rit'CTW-'N I'IW,1? :101,.000-418,000
L'PROVIG BI.0Tii„YN FEE: - Rfraltl t 0 1 000- 21,4 1 -0 0 $2.00
�q�ili.
_
FEB 0 3 2UO3
CITY OF LA QUINTA
FINANCE DEPT.
"=noi;t:F�'►r.ltn�
:C F+ S'S .F.R�,uao.A1,t"i.5 TiEllls
$101 l
Tf TAL P RRMIC Y ES 1 OF, NOW
1009 to
RECEIPT
DATE,,
BY
INSP T R
{
,
Pae
g of
DAVE STEAVENS
Inspection Services ;.
PROJECT (A b 5
ADDRESS 7
-ZU V 4rdA?E55 Pl A J /7 h 4G /7
BLDG. PERMIT #
ENGINEER ti u
INSPECTION TYPE
PROJECT # ;2,0 p 3 -
CLIENT wGii j) g� 5-7-- /./DA
DATE
ARCHITECT Cox. 1 A 4A?e N
CONTRACTOR -bt L ^4 !T Cii'(c'
INSPECTION REPORT
LIS •• `tA I `7 � .3X �D5 SCS? iJS l)A, /L',JG 6.i111.f_7^t
5
It7 - /G% 7- ZPi. -9 ,
-�
�Ij4rl�LS 7�GyCilis%C,��<7�t -C..yN+ 0LrT
CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
b
"•stantially complies with approved plans, specifications and applicable sections of the building codes. This report covers
:ue locations of'tfie work inspected only and does not constitute engineering opinion or project control.
i
ERT. NO.D_`� `� C� INSPECTOR NAME A KI S
(Pr Cleary) •..:�
DATE ll i;'R 1 C_ INSPECTOR SIGNATURE
v