0104-226 (BLDG)LICENSED CONTRACTOR DECLARATION
I NwiWirm under penalty of perjury that I am licensed under provisions of
Chap (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
733!57. FJ () 1?11.127
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).
( ) I, as owner of the` property, am exclusively contracting with licensed
contractors to construct the -project (Sec. 7044, Business & Professionals
Code):
( ) 1 am exempt under Section B&P.C. for.this reason
Date Signature, of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under, penal ty,of,,perjury one of the following _dedarations:
O 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 worVfor'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.
CAL
(This section need.not be completed, if the permit valuation is for $100.00 or less).
O ('certify that in the performance of the work for which this permiiis issued,
I shall not employ any person in any, manner so'as to become subject to the
workers' conipensation laws of California,.and:agree that if 1 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 FaiILIre 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 180 days will subject permit to cancellation.
1 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 PERMIT#
-10DATE •
VALUATION LOT 0104-'226 TRACT
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2000M
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SITE
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ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEERkt.
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DE, MAR PACIFIC; b"f2.ALiE9QN°!'�211C�Pt7
CA 92253
146 AWA BRACE CA 92093
(558} 62-1 SOC) CNA
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USE OF PERMIT
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APR 2 0 2001
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CITY OF LA OUINIA
I BY DATE FINALED INSPECTOR
IN hFEC' ION REPORT
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CERTIFICATION OF COMPLIANCE To the best of our knowledge,- all oft he .reported work, unless otherwise noted,
substantially complies with approved plans;'specifications and. applicable sections of tFie buildirig codes. This, report covers
v,the locations of the work inspected'only and,does not constitute engineering opinion.orprojedcontrol. '
CERT. NO. � 3 - 'U < INSPECTOR NAME
DATE 13 -,Tu L yINSPECTOR SIGNATU
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CERTIFICATION OFCOMPLIANCE To the best of our. knowledge, alhof theireported work unless otherwise.noted,
substantially complies with aprovedjplans, specifications and applicable sections of'4he:build(ng.codes.rhis report covers
e locations of the work inspected.:,only-and does -not constitute: enginbenng:opinion or project control.
CERL PLO. INSPECTOR NAME.'1 3i SIC: aT� ✓• ,:i-�
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CERTIFICATION OFCOMPLIANCE To the best of our. knowledge, alhof theireported work unless otherwise.noted,
substantially complies with aprovedjplans, specifications and applicable sections of'4he:build(ng.codes.rhis report covers
e locations of the work inspected.:,only-and does -not constitute: enginbenng:opinion or project control.
CERL PLO. INSPECTOR NAME.'1 3i SIC: aT� ✓• ,:i-�
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DATE __ �K Ly �•Ufl INSPECTQR SIGNATURE ` ��