0109-148 (RR)O�
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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 # Llc. Class Exp. Date
770M 0319 H .1113101
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 (Seca 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).,,',
O I am ex mpt , der Section , B&PC: for this reasf n ?
Date Signature of• Owner ' _.
WORKER'S COMPENSATION DECLARATION
el hereby affirm under penalty of,perjurytone 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 willmaintain 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.
(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 should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I sha I fort ith comply with those p ovisions.
Date, '� Applicant J`d I p'
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 attorney's fees.
IMPORTANT. Application is hereby made totheDirector of Building and Safety
for a permit subject to. he 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 appllcaton agrees to, & shall, indemnity
& 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 prop, rty,4or inspection purpose
Signature (Owner/A' ent)" t Date /�d 16-1'
WILUINU Ft:KMI1 , xti T
IDATE / I VALUATION LOT 0109-148i (,�3�•TRACT':. ;
JOB SITE ¢;
ADDRESS, /� a
APN
V'r OAX
OWNER
CONTRACTOR /DESIGNER / EN INFER t:4
F'C3A Ri��lflMMAL, HO V1RMS
fi� ROOFMO
R01 BOX 106)
83-597 PHAICH 3T,
L,A WINTA
WD10 CA 92201
(760)347.9569 CBL* 3978
USE OF PERMIT
C3�nI��tAT.I3'iTI1.Z�137C3
.
R&ROCIP WITH CLASS A MATERIALS- BLDG l4: 54-100,14-1109,
S4� -iii-124 .
VAIXATION $ 1,300,00 is
i� fh► D COST OF CC)MMUC 014
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RXROOP' M 1®1 ,(100.41+R•4 :39,00
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$30.00
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i $0.00
SAL P1M1' MMODim 7P601W
$90.00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR