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0109-149 (RR)I hereby affirm under penalty of perjury that .1 am licensed, under provisions of w a t 'Wei ,: _ - P c ). ,� tiF LUINtai t� 11111 I �L h _ NChapter 9 (commencing SeCtlon 701 otDivision, 3"of the 13usineas and r; DATE {` ,t.` 3,;VALUATION a • _> , LOT�''+�}. O1b09-4$ j 7 s'• eq Professionals Code, and my License is In 'full force and effect.; ° ' �?J ♦ F x " 0 5 `�/� License# 'Uc-bass :Exp, Date f rii.(# t • ,' • '�` # t107�.:7 w� 1 8. + rAxN t #`.0 '�I'a%GCN•x #+ 7:Y '�1 •�3Si. 1A 1"S P JOB SITE r r y • n SLc Y'" 'ec io r �4 APN a. f d i ?, r 'y"" i t `• ADDRESS �'I 710940 F c3 1 it�ota� SLf i o'aAK Uft Z Date Signature of Contractor * r " OWNER r4, jx �,1'y� 1CONTRACTOR /t)ESIO�NgERENGINEER 2v,t } { ,• d:t _ r •K, r• ... ::, >,'^•,Ei =. y-.;.E'&.�('A..t .rl✓.�'S•1'�•1�,';Fy:''"S,� ct ' "�. ' $r 'i'�ik' ru *''• so OWNER -BUILDER DECLARATION t., ys�Kx � v : PCNA WW l i 'iiA . �I©i�pWi3I 1 i�iFRALD RQ4l�IAiC W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's f' .. " iA`• zt ° ` a F.O. DOX 1060 Y P ty. P rl ry P '.83 597 PEACH 8T, to License Law for the followingreason: , ` , , property, or m ;em to ees with_wa es as thelr sole 1�AQUII3TA ' * +' r ' ` LNDIO , ;' t GA'a;BZ01 t Z (:) I, as owner of 'they p y g �- t ; ,� ,• �' compensation,.will do the work, and the structure Is_notdntended or offered for •: '' '` (760)347-9"9 n �_�� 5978 v s�e (Sec 7044,: Business &'Pfofessionals Code). t USE OF PERMIT t r `(J) I, as"owner of the property, am exclusively, contracting with, licensed + b' , ��� ntractors to construct the project (Sec. 7044,°Business`&';Professionals-GENERALBUl1�?1N1Ci" c'S:s ex MI if under Section ¢ a&PC.'for.this'reason^• 1' # ` , "`'-Rti�l�' OITH C1:ASA JWdA7'1ilAI.'flLd3Cf Nl. S4•E3 )ate' `1 .�. Signature''o�f+Owner .?�:�' ';.~ .:54.1A, 34-116 k< �A 1 Q� 'i,; �r fi'r .4�A - ..f�§F: ufa..-'i,t�S' ,�i�,e_r ,r - ., `:� 't..i.L M1>,: •air. �f..' - r. t1:} J, ..t". a,Z •.11,11 1*WORKER Se COMPENSATION DECLARATION.# Jia `� 4+ y RECEIPT Y DATEBY DATE FINALED INSPECTOR 8;�`Q �.I hereby -affirm -under -`penalty; of penury;one;of,the following=declarations: �.i, It ��''� r L�114}�. i ` , ° Q ►- o t LL i ` I have and will malntalri a certificate of consent to self-insure.for workers" . , .c ). , . is fo�kby,Section 3700 ,; • t . �r wu�Tto>� . 1.500.00 LS cf 1 g 2001 X W J _J § t`compensation; provided of the Labor Code for the performance performance of the work for which this permit is issued I'S .�!-, �� U', have and wlll.'maintain workers compensation Insurance as required by -�? CITY F EPT. ' D Q Section 3700 of �e Labor Code, for the performance of the:work for•which this , ' f. =r . FI ANCE n.•� !Q—� c permlt'Is,issued1My workers' compensation Insurance camera& policy no pare:, :r Z ti Gariel ,. , ;.. • r :. = Policy No. Co. -8TATfs'�D nrpdAT=ccosy or, cammrare x ouu + "r (This section need not be completed If the permit valuation is for,$100.00 or less):^ ��� JU' �i11b"Y =p Y J )1I certifythat in'the performance.of the work for which this permit is issued, • REROOF FEF, 10100. µ'418-CUo �• ` $30.00 w • .3 v • I shall not employ any person in'any manner so as to become subject to the workers' compensation `iaws of, California, and agree that if I should become - ` - subject' to the workers'., compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those prgvisions. y . Date. 771 Applicant :Warning: 4 Fail ure to secure Workers Compensation coverage Is unlawful and A ',shall subject an'emp16yerto criminal penalties and civil fines up to $100,000; in , raddition to the cost of compensation, damages as prowded.forin Section 3706 ,v>� •`•'of the Labor Code; interest and attorney's fees F`- > { x t s irk+; * IMPORTANTAppllcatlon is hereby made to the Director of Building and Safety �;; `the _. r .. „ .,.•,► . r• i for. a, permitysubJect to conditions r and ?restrictions • set forth on.,, his ' ' Zt! r `�apjilication � 5 � w 2 [ Tis � ', •° r ••.0 ,� hY."' .F y .y r !{.'I > �.. 1.,Each person' upon: whose behalf this application Is made & each person at` = zwhose ,. ,;_ request and for whose benefit work,is performed under or pursuant to OUB -TOTAL CONMRUCI'j01+i'AND PLAN CIHYi,4,K'',. $30.00a a x any permit Issued as'wresuit of`this ap' 116aton agrees,6 & shall; Indemnify ' • r. T.B9: M.-FAMPM ; $0.00 � : &'hold' harmless; the City of La'QUlnta;;Its officers;. agents and employees:• �V tr2. Any permit assued`as"a result of this application becomes null and void if � -` r, " �` z:r -1 I • :.. }work is not, commenced within 180,'days_from date of,,Issuance;of such r :, 7itY1'AAL Fkil' F8'>i DUE IdAMP ., 5- . 'k rx permit, or cessation=of work for 1f30 days,will subJect permit to cancellation. `, ^Z. ` t 1 K, .. .. {°p^YT , - _ r,'>R .11certify that l have readthis application andatate that the-66ve Information iso •t, .ur ' .r .. .i5. S< k f`, ,1•. '� ^g, yK, • .. a, correct. I'agrge to comply with all City,,an&State laws relating to the'bullding construction;`and hereby'authorize re resentatives of this.Ci to eriter,u on, ;. P h! . P . pl, .,)'the above-mentloned property,for. inspection purposes c fi� 0 • yi t ir/ ,. `� 4+ y RECEIPT Y DATEBY DATE FINALED INSPECTOR � . �� r ��.�y� t �} �a � � �.i, It ��''� r L�114}�. i ` , ° � w iia '7 �' ,�C,n � ; 'I.µ c S ���614 • r;- L. • _�'r"�1�.� ��}�� .rM1N. ;:Il -tea. �� .�!-, ��