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0109-148 (RR)I hereby affirm under penalty of perjury that I am licensed under provisions of I-- ; Chapter 9 (commencing with Section 7000) of Division 3 of the Business and CV W Professionals Code, and my License is in full force and effect. p n ch License # Lic. Class Exp. Date Cy UJ CC 770940 0391 a 1l/�0/OI cZ Date Signature of Contractor • . O r` J L) tp OWNER -BUILDER DECLARATION W UJ I hereby affirm under penalty of perjury that I am exempt from the Contractor's' 0. N 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 sap (Sec. 7044, Business & Professiorials;Code). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.. 7044,. Business & Professionals Code). O I arn,ex mpt ` der Section B&PC. for this re ns ' O Date Signature of. Owner '�J, �' 1 . / .✓' ... (L Z WORKER'S COMPENSATION DECLARATION p XI hereby affirm under penalty of perjury. one of the following declarations: In P 0 () 1 have and will maintain a certificate of consent to self -insure for workers' X W u' compensation, as provided for by- Section 3700 • of the Labor Code, for the Om J Q performance of the work for which this permit is Issued. Q L) () I have, and will maintain workers' compensation insurance, as required by OU Section 3700 of the Labor Code, for the performance of the work for which this a rn H permit Is Issued., My workers' compensation insurance' carrier & policy no. are: Z Cartier Policy No.., ' Go O = STATZ 1�1A1D -QD-0001997. . (This section need not be completed if the permit valuation is for $100.00 or less). �ti O I certity,that in the performance of the work for which this permit is issued, I shall not employ any person in any mariner sous to become subject to the workers' compensation laws of California, and agree that if 1 should become . subject to the workers' compensation provisions of Section 3700 of the Labor 3 Code, sha)I-fortl ith comply with those provis4k, Date: � Applicants„ �' .. Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to. $100,000, in addition to the cost of'compensation, damages as provided for in Section 3706 of the Labor Code; Interest and attorneys fees IMPORTANT Application is hereby made to the Director'of Building and Safety 1 ; for a permit subject to the conditions and' restrictions set forth on his - 'application 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnity ,. ...& hold harmless the City of La Quinta,•its-off icers, agents 'and employees., 2. Any permit Issued as a result of this application becomes null and void if work Is not commenced within 180 days from 'date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation: I certify that I have read this'application and state that the above Information Is • '. "correct. I agree to comply with all City, and'State laws relating to the building c6nstrugtion, and, hereby;'authorize representatives of this City to enter upon 'the above-mentioned proprty r inspection purpose f p Signature (Owner! f Ant) `' Date , r ; DU1LUHIM .rCi'S m i., ati CT DATE �, J VALUATION LOT O1a9-14� TRAJOB SITE ADDRESS�/�00 �. J7' OIfiTR$� APN j a OWNER CONTRACTOR/DESIGNER/EN INEER POA WM RRMIMT AL HOMM)WNM i MAEgfiJLD ROOI+MO RJC . P.O, BOX 1064. 83.597. PUM, 3T.. = :` t L,A d UJNTA 1),1DI0 ; CA 92201 (760)347-9889'. CSL# 5978 USE OF PERMIT M4190LT3i.TLDING RILROOP WITH GLIAS. A MATERIALS- BLDG 19: 54•MOily —IW4 ; 54-116, S4.12I VALUATION 1'"0,00 LS e� \ COS!' ON COMM'pC: 014 PER r Fu HQeau "y RKROOF WE 107'=000.4111 -GHQ© :30,Q0 4 h SEP .� F�NCp/Nt'4 SM -TOTAL COl~ISeMUCTION AND PLAN _ ' ,. $3t?,00 lam$ PRE,' :r' $0.001' TOTAL PTFdW YAM !DUE >�(D�ist ` $30.40 . RECEIPT D(:TE /, BY DATE FINALED INSPECTOR.