0109-148 (RR)I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 70W) of Division 3 of ,the Business and
N W Professionals Code, and my License is in Of force and effect. a
C License # LIc Class Eiip. Date''
ti LU' 770M ",:C39'1 11P30{01-
6 Z I-- Date Signature of`Contractor
ie O
I— Q OWNER -BUILDER DECLARATION,. k,
J U Q . „. r t
W W I hereby affirm under penalty of perjury that 1 am exempt from the ContractoesF
~ CL License Law for the following reason
Z ( ) I, as ownerof the'property, or my a employees,with'wages as their sole
compensation, will do the work; and the structure is not intended oroffered for
Sate(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
� O I am ax pt der Section ►' , B&P . for t is re7son � fi
Dates Signaturetof Owner >� +
r.., : * ` �, 4:i ..►.'moi,'•" �}•: ;: ti +ar's•_ ..
U Q _ WORKER'S COMPENSATION DECLARATION
Q Z I hereby affirm under penalty'of perjury.one,of the°'following; declarations:
H 0 ('.) 1 have and will maintain a certificate of consent to•self-insure for workers'
X W u-' compensation,,, provided for by.Section;3700 of the Labor Code for the
J Q,, performance of ilia work for which this permit Is Issued :F
ca Q U • (') "; I have and will maintain workers' compensation insurance, as required by • `
d U Section 3700 of the Labor.Code, for the performance of the work for which this
a H 'i permit is issuedsMy workers' compensation Insurance' carrier & policy no. are: '
Carrier, . a
'T Z Policy No','
00" O $TATER .t11�iTi 1' �9-40.0G019�7s' :4
r• .'
• f.. S C 1' T mak.
r (This section need not be completed ff the permit valuation Is for$100.00 or less).
I certity,that in the performance of the work'for,whicfi this'permit is issued, "
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
3 L4 -! subject to the workers' compensation provisions of Section 3700 of the, Labor
Code, I sha I fort dth comply with those provisi s/: '
Date Applicant�T—i�F7
if.}.
Warning: Failure to secure Workers' Compensation coverage is unlawfufand
shall subject an employer to cnminal penalties and civil fines up to. $100,000, in
addition to the cost of compensation damages as provided for in Section 3706
1111110. <P of the Labor Code, interest and attomey's fees.,,
tr IMPORTANT .; pplicatlon.is hereby made to the Dir•ector:of Building and Safety
.l 4for -a,permit•sublect toathe,conditions`and`'restrictions set;forth"on'"his
application xt r c• .. y C� ` ' ;; ";
.1. Each person upon whose.behalf this applicatiomis made &each person at
whose request and for whose benefit 'work is performed under or pursuant to
st; T any permitdssued as,a result of this appllcaton agrees to, •& shall,!indemnity
'7o.4& hold harmless the`City of La Quinti 'Its officers :agents and employees:'••
2. Any permit Issued as a'result of this application becomes null'and void if
a work isnot commenced withint' 180'6y9.from - date' of• Issuance of .'such
permit, or cessatlon of work for;180 days will'subject permit to cancellation.:,
°1t Certity that I have read this'application and state that the above Information Is
• 1 � correct.,l agree to comply with all City, -and Slati laWs''relating to the' building
,122 �,cbnstruOlon, and. herebylauthorize representatives'of this City to enter upon
s
the above mentionedprop' rty pr Inspec'Ion purpose x
17.
Signature (Owner/tent)' �' `Date /.
..Fv
,d, y.T'�lo.'r, �t•...'a'Y;. 4.;L; Y...9''. -;�. _..,... i,tnf[ cj .. _
...VALUATION `i'1.�j9j"d` LOT;VIt Tit ii.�ii�r+ :TRA CT�/
GATE ' yyJ j��`,
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r: r3�V•y
,f t 1". ?':�"' >',s?,. +';Y� a;. ie' +'+y�.,��xl, g',a .«•i �-t.��_
JOB SITE "s� P] c Y � ►+:f;;
ADDR °'
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OWNER „ , r !T Hyl t • .
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f Y. f• �. ` i, '. �r1A j , "bI� �. •.
CONTRACTOR / DESIGNER / ENGINEER f --f'4' + r j
.�7'; +f* t J -a y �; J.�yr "i5 Z� � �..i � ��A ��'v ^. ��;. �J
$10"
�` �h� ttl� �yy��� t�Y �►�t?l����B
a• l'," R9 RR MMMA + HOJO A.f NERS
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M� �' ���y D/������y, 7��•� i}i�ilFi�/ '�•
ALD it�,/Vlii .11' .µ,
P.0: BOX 1060 �� � �� � ; `
'`�83'39?'P29AICH �. k � ``; r�•
* A �•�� t .y r � •Y. 4„'
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Tp� ir, r, ,^i} � i” t �� .
` �l�! S"�t iF<r
T_
1 < • .: r. ,'
. a'•j i4IL�QI erf�o,
. s•. '(760)347-9869
- s>
USE OF PERMIT
a1 i ALi 1 DUUMISO
}: f€ ROUIs WI't't1 CLASS A MATERIALS- BLDG 10: 94-M 3440, '• �?'
�
VALUATION � a.. 1'"0.00 L8
,
p ' D COST OF. C'010TRU iOR
P .r ll YX f UKh14RY
104'00.41S-10KI0WOOF F$ l00
0 y.
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"-=AL C'C?MMCTION MD PLAN :+ ,t _ 't
;. $30.00:
&PNMW FM DUE NOiliE
RECEIPTDATE
/
By
DATE FINALED
INSPECTOR