0109-149 (RR)H
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I hereby affirm under penalty of perjury that [.amlicensed 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 # Lica: Class Exp. Date
770"o C39 i 11t30l01
Date Signature of Contractor
OWNER -BUILDER DECLARATION,
I hereby affirm under�penalty of perjury that am exempt from the Contractor's
License Law for the following reason:
(') I, as owner of the property, or my, employees wl,h,wages as their sole
compensation;. will do the work,. and the structure is not intended or offered for
seje (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).; , z .;.' ..
(,) I am ex mpt nder'Section B&P C. fothis reason f
Date
Signature of ,Owner "'
,,'
WORKER'S COMPENSATION DECLARATION
I hereby affirm. under penalty of perjury ,one,of theyfollowing declarations:
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 work for 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.
• �Ar>3:��r1p � ' has-�o-o41u1��
(This section need not, be completed If the permit valuation Is for $100.00 or less).
O I certity'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 provision's of Section 3700 of the Labor
Code, I shall fort with comply with those pr9visions.
Date: '" Applicant t 1,. / r .J %
V jt
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 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 tlils 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 Quints, Its officers, agents and employees.
x: 2. Any permit Issued as -a result of this application becomes null and void if
<� work isnot 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 property for Inspection purposa�jj_Date
` t 4 Signature (Owner7Age t) ` i ` r
BUILDING PERMIT...
DATE ; / VALUATION '. ; LOT .:
01W,149,' - TRACT
JOB SITE
ADDRESS AAMC
APN
y
OWNER
CONTRACTOR/DESIGNER/EN 1NEER
�f
PGA %FTP UMMIAL H0MWWNMt
SO la"MF..R AM R00MG, INC.f, °? `
P.O. BOX 1060 '
83.597 PEACH SIT',
LA QUNrA
INDIO CA 92201
-76(1)347-9868 CKA 3978
USE OF PERMIT
C3fi:�7I?RAL BITMUNG
RF,ROOF WITH CLASS A MATERlAIZ 13JA)O 20:34.13Z 94.144 ,.
g4.14S4-1g6 ;
VALUATION 1.509.00 LS SEP
18 2001
F QUINTA
CITY
ANCE DEPT.
FI
1Q A'1 D Gobi' 0I+ COPI IMUCIMON
:T'76s'Yd1S4Vf`I")! Huhn &&"
REROOF FiR 101 �000 -118-1900
SUB TOTAL CO.NVIRUCTION AND PLAN C2MCK
$30.00
LEM PRE -PAID FM
$0.00
TOTAL PEOW I DUE NOW
�i�DAq
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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