0109-150 (RR)to
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I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
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DATE VALUATION LOT - . f Q)L0-1<ii TRACT
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Professionals Code, and my License is in full force and effect.
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License # Lic. Class Exp. Date
JOB SITE
ADDRESS �/� 9 p
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LLJ770940
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Date Signature Of Contractor
OWNER
CONTRACTOR /DESIGNER / EN INEER
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OWNER -BUILDER DECLARATION,
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I hereby affirm under penalty of perjury that I am exempt from the Contractor's
P.O. BOX l ow
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License Law for the following reason:
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( ) I; as owner, of the property, or my employees with wages as their sole
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compensation,, will do the work, and the structure is not intended or offered for
s le (Sec. 7044, Business & Professionals Code).
USE OF PERMIT
(,) I, as owner of the property, am exclusively contracting with licensed
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contractors to - construct the project (Sec. 7044, Businoss & Professionals
GENKRALBURDINO
Code).
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am m tnder Section B&P :for i res o
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Date Signature' Owner '`
il&id0#iN 61i'1'RI1 CLASS A MA7'�itlA1S• aGl?0 21: 31.164, 3Q•I` 1% 'i A '
54-111 $4 { 3 D '`
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WORKER'S COMPENSATION DECLARATION ;.
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1 hereby affirm under penalty of perjury one *of the following declarations:
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O- I tiaye and will maintain a certificate of consent to self insure for workers'
VAIA)ATION
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•compensation,- as provided for by Section 3700 of the Labor Code, for the
CITY OF LA QUINTA
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performance of the work for which this permit Is"Issued.
FINANCE DEPT
I have and will maintain workers' compensation insurance, as required by
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Section 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 & policy no. are:.;
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Carrier, Policy No.'
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STATZ PUNA
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ESI` MA*IXD Coyr OF C0119 4t1ITMon
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(This section need not be completed if the permit valuation is for $100.00 or less):
PIMMU M 9111NMARY
O I certify that in the performance of the work for which this permit is issued,
REROOP FEE1 tD1.4tU0d418^V00 $;3t44f1
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
3`
Code, I shat fortith comply with
Fjrpvi,sionf r'
Tose,
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 Appllcation;is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
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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
-TMAL CONM11MON .RNID PLAN' CMM
1$30.00
any permit Issued as a result of this applicaton agrees to, & shall, indemnify
mac? PRI -PAW MM
$0.00
& hold harmless the City of La Quints, Its officers, agents and employees.
2. Any permit Issued 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 PXRMr1 8 YiUl NOW
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permit, or cessation of work for 180 days will subject permit to cancellation.
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-mentloned property for Ins action purposes. ,
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RECEIPT
DATE .� j
/
BY
DATE FINALED
INSPECTOR
Signature (Owner/Agent) ? ! ` Date `
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