0109-150 (RR)FN—
N t)
W
ouch
Ir W
oZ^
O O
H�
LLiLU
a�
CO
Z
hereby affirm under penalty of perjury that I am licensed under provisions of UILVINU F+t�lM1
r,
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DALE VALUATION LOT O�O'9-1'�0 TRACT.
'
Professionals Code, and my License is in full force and effect. ,
License # Uc. Class Exp. Date ' , ? k
JV6 AI I C
77f�0 C39 WC 11/30/01 ADDRESS_'FQO�ii
Date Signature of Contractor OWNER
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or'my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
(,) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Businoss & Professionals
Code). ;
O 1 am x mpt der Section B&P. for i t )a o !
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
() 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.
STATE. R MD .285-0-001997
(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,
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 370 of the Labor
Code, I shat fortith comply with t ose' pvision
Date: < Applicant /
Warning: Failure to secure Workers' Compensation coverage Is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, Interest and attorney's fees.
IMPORTANT Applicatlon,is hereby made to tfie Director of Building and Safety
for a permit subject to the conditions: and restrictions set forth on -.his
..application. .
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to RM TMAL C".ONBMUCTION AND PIM (°FiWK
any permit Issued as a result of this applicaton.agrees to, & shall, Indemnity I� � F
alp & hold harmless'th4,City of La Quinta,'Its officers, agents and employees.
AIDPM
2 -.'Any permit'lssued as a result of this application becomes null and void If
.► ' work Is not commenced within 180 days from date of Issuance of such TOTAL PMWTFNES 011E HOW
permit, or cessation Of Work.for 180 Jaya -111 ubject permit to cancellation.
' I certify that I have read this application and state that the above Information is
• correct. I agree to comply with all City, and'State laws relating to the building
construction, and hereby. authorize representatives of this City to enter upon
t`.the above-mentioned property fo�lnspaction purposes
RECEIPT DATE f BY
, Slgnat6re (Owner/Agent) I '{ Date47
PGA REMEATITAL HOMEOv�tM
P.O, I+C�?G 1060
LA QUJNTA
USE OF PERMIT
Rt1f1<ROOY'WITH i":t...9$,J A MATERIALS- HLD0 21; 34464, 54.17?,
��-1138 r .
VALUATION
1,500.00 Is
Lr S'1'BMX1� CO3ST OF CONS1RUCTtON
T'1f TM rr FEE SUMMARY
KEROOF FEE 101 -000--416-WO g�.4f1
DATE FINALED
18 2001
CITY OF LA QUINTA
FINANCE DEPT
..1151)0.00
$30.00
$0.00
SO.01;')
DNTRACTOR/DESIGNER /ENGINEER
r
9 U ROOF11 O, }1`TC
83.597 PLALLi
]� DIO
CA ; 92201
(76Q)34'1-9668
CBL# 5976
Rt1f1<ROOY'WITH i":t...9$,J A MATERIALS- HLD0 21; 34464, 54.17?,
��-1138 r .
VALUATION
1,500.00 Is
Lr S'1'BMX1� CO3ST OF CONS1RUCTtON
T'1f TM rr FEE SUMMARY
KEROOF FEE 101 -000--416-WO g�.4f1
DATE FINALED
18 2001
CITY OF LA QUINTA
FINANCE DEPT
..1151)0.00
$30.00
$0.00
SO.01;')