0109-149 (RR)y
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I hereby affirm under penalty of perjury that I am licensed under provisions of
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Chapter 9 (commencing with Section 7000) of Division.3 of the Business and
Professionals Code, and my License is infull force and effect. -
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DATE VALON LOT p f' ���(� ,TRACT
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License # Llc. Class Exp. Date
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Date Signature Of Contractor
OWNER r
CONTRACTOR /DESIGNER /fN INEER
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OWNER -BUILDER DECLARATION
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hereby affirm under penalty of perjury that lam exempt from the Contractor's
1110. BOX 1060 .
83-597 P78'�►Qi g!; t
to
License Law for the following reason:
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TNDIO CA 98201
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( ) I, as owner of the property, or my employees with wages as their sole
(70P)347-9869 CBI O 5978
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
USE OF PERMIT
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(/) I, as owner of the property, am exclusively contracting with licensed
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YOntractors to construct the project (Sec. 7044, Business & Professionals.
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Code).
O I am exempt under Section , B&RC. for this reason
RF ROOF WITH CLASS MATERIAlLR- BLOO 20: 34-132, 34-140, ; ..
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Date Signature` of Owner ,1. '
54145, 116
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WORKER'S COMPENSATION DECLARATION
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I hereby affirm under'penalty of perjury one of the following declarations:
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(`) 1 have and will maintain a certificate of consent to self -insure for workers'
compensation; as
VALUATION 1.500,00 LS P;Jkoa
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provided for by -Section 3700 of the Labor Code, for the
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of the work for which this permit is issued.
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O I have and will maintain workers' compensation insurance, as required by
Section
CITYDE TTAO
DEP
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3700 of the Labor Code, for the performance of the work for which this
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permit is issued.'My workers' compensation insurance carrier:& no. are:
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Carrier Policy No.
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ENME417.1;12 POST Olt C01U1RtTCnOJR
(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,
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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
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Code, I shall fortwith comply with those provisions.
Date: ,. Applicant % 4f a" J91
- 14.111 %..t,. -
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties -and civil fines up to $100,000, it
addition to the cost of compensation;_ damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees..
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IMPORTANT Application is hereby made to the Director, of Building and Safety
for a permit _ subject 7to•' 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
OUB- AL, C'ONff1 UC'1TC'fN AND PLAN' C M=-; >Z30.Q0
30.00
any permit Issued as a result of this applicaton agrees to, -.& shall,. indemnify
PRBaFAM
& 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
Is not commenced within 180 days from date of Issuance of.such;`
1, P1 TF DU, NOW
': permit, or cessation of work for 180 days will Subject permit to cancellation. '
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certify that I Have read this application and State that the above Information is
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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 purposes
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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Signature (Owner/Agent) Y �` j` Date
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