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0109-150 (RR)I hereby affirm under penalty of perjury that I am licensed under provisions of -II-- Chapter 9 (commencing with Section 7000).of Division 3 of the Business and (V W Professionals Code, and my License is in full force and effect. -4. C M License t/ I, LIC. Class, Exp. Date CY to W 770940 ` ca9xl 11/30/01' Z r- Date ~' Signature of Contractor0. s d OWNER -BUILDER DECLARATION • JL)(D W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's ~ it License Law for the following reason:,. Z_" ( ) I, as owner, of the. property, or my employees witti wages as.their sole Compensation,, will do the work; and the structure is not intended or, offered for (Sec 7044; Business & Professionals Code)., Mf.'' I, as owner, of the property, am exclusively contracting with licensed contractors to construct the project (Sec:�r7044,, Businoss,&. rofessionals ' Code) s . , ^'O I am x pt der Section (• & ^;8&PC. f I ea o •" • yul)" Dater .. `Signature of Ow.jn}er' r'r O'i ,t <'L�;,.�s ,�Y'i -.t ' r 7 �. '?TI3•..x U Q `'rWORKER'SCOMPENSATIONDECLARATION"ii'k, 'Q L hereby aff rm,uner;dpenalty, of,pedury one (of,,the following declarations:, � p , O. 1 have and will maintain a certificatewof consent to self -Insure for workers'_. X W:9 ,compensation;,1as;providedfor.,by Sectioni3700rof the Latio� Code for.the. O � Q ''performance of the work for which this permit is Issued. `fir= I have and will, maintain workers compensationinsurance, as required by - 0 y.O;V . F Section 3700 of the Labor Code, for' the performance of the work for; which this • it rn'.H ` permit is` issued'My workers' compensation insurance tamer: &policy no: are: �., Policy I �, `- I., `rye r� err STATE MND: � �. y F. • + —I CV, t Mgr ; (This section need not be completed if tie pemti 'valuation is for $100.00 or less). " (t) 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 , " k workers' compensation' laws of, Califomia;.a6d agree that if I I should become t " subject to the workers' compensation provisions of Section 370 of the Labor Code,'I shat fort ith comply with os ' vision . 3 Dater Applicant' ' �. a' Warning: Failureto secure Workers 'Compensation coverage -is unlawful and } # shall subject anemployer 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 Appllcationis hereby made'to'the Director of Building and Safety Frfor^a permit subject to", the-, conditions, and, urestrictions"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 i,: any permit Issued as'a'result of this applicaton agrees to, & shall, indemnity & holdharmless the,Cltj of La,Quinta its, officers, agents and employees.; 2. Any permit Issued as a result of this application becomes null and void if ' '+ < ;i work is not commenced whin 180'days.from date of'issuance'of such permit, or cessation of work for 180'days will subject permit to cancellation. 4 I certify that j have read this applicatlon and state that the above information Is • r ' correct. I agree to comply with all Clty' and. State laws relating to'the building 'construction; and hereby authorize representatives of this City to enter upon t , the above mentloned property for Ins action purposes.,/�� t c a /.', " { Signature (Owner/Agent) a F ° 5' Date VILVINU r ��'■1"'"�,� °� r`r +� r'?� ,w�ba y n+' r F5` i i # VALUATION e LOTS ti. TRACT DATE ,,. Q)l�-1�V.„,_Qt,r ,: 7. Y tt. -�. `3, ?;� 'x w s i .. .�. r .ra:_.f Ilk I JOB SITE v 3f� s�*, ;;” ADDRESSrj`j APN OWNER i r •� "� Y� :�.� �tiF,r CONTRACTOR / DESIGNER? EN (NEER r y t fit: •ti';"r: •.aw y r S wmi,�i :/ ,..x. 5,�..: =P<3A'V' T R @EN`t'tAI:H©A O'VIN .a� ROOFWG 1�1C.O a i•(: 31. �� J3OX 1� � ., K.+'¢O:k-597 r�.. T PEACH R � LeA'fjidll�iA E= .. II1D10 '� , CA: 9201' s :3 , ' , (+0)347 9889; CBT.d#' 5978 USE OF PERMIT) `1' liLdJ.Li1Q' x,. . S #�: .. ' V.C.�� l7V H�''�1 ^ /, c w • -.. c t -C �, ?.• • y - a.' ..' ► -. -, / ♦ is - .k ldl&gdOAIP IVI O CLAS'S A MATORLU.S. BLIDO 21: 34.184, '54-It1t►.S4*It;fi p�jr ':y p+. +,.� , srr D lu 81 001 VAIMATION/ , I,S�,QO 1, cITY of` LA QUINTA>? FINANCE DEPT' ; t r'rmmr ' b 9UMMARY ; 1tERO FEE ` ` 1 A 1-00(iY418�000 g tO, Otl -TOrAca CONsr UCIMON AND pr:Ata' C3W $30.00 °. Ia= PR&PAU F :. s0.00 a Y r x` r '., TOTAL PXRbii' FXES riUE NOWI ' >�►o qo RECEIPT DATE BY DATE FINALED INSPECTOR �i441ff: c _. __rte:_. _.,__ .,...l....c - r" +..c=a..-.a•�._...—_ _..... _...... �-. �._...-..• _.....a_......_..rr..`.r. ° �;..�k_._.;.._.�,_._.: .._.,�_._�.._......-.__ ,�.�_.r..._ �_.,_ �.. _,.— --