0109-151 (RR)I hereby affirm under penalty of perjury.that I am licensed under provisions of 13 ILUING FF.HMIT
Chapter 9 (commencing with Section ,7000)Bf DIVIiion 3'of the Busiriesi'and A
DATI'E
Professionals Code, and my UcefisB Is 16 full force and effect. !
License # 1.1c., Class 6p. Date �i�uu:TION .
JOB SITE
f-
_4 ADDRESS'
0ARTIM
770940 1113offil
Date Signature of Contractor
05i
",.-�--OWNER -BUILDER DECLARATION
;4� 'W'
A
T
*Y,y"I., * fir,1f. At.d
I hereby affirm under penalty of perjury that'l am exempt from the Contractor'sP.O.
WX 1060
JM U0,=&VJ.V.4%&%LAW 4%%fW.VAJM%J) ACVA
%Adt ST.
License Law fog hi following reason
1, as owner the ii�ployees 'with wages _ds thelr:6ole -
iA Qu&rA
INAIO 11 -i� ; � Ck"922011
t , , , �,, I �,
property, orAy
compensaI6,'Q11 do the the stricture isnot Intended for
$�
- - ... ! �� . - -
11(7 CBL#. 97 6
Work.L and or offered
sale (Sec .,7044 I 4Busless&professloA'alsCbde)-
USE OF PERMIT
t6whiqr,; of the "pr6perty, armLeiiluslvdly•4ithillceinsed
ntractonT h 6ilnesl :&-"Profeiilorials, f
7044-B S
e"project eq.
GVAH1ALB*URZ1HG,'2'-
.�o�:construcl:411
4Ccide)--
11% U
am GXGMIok
tWer Section B&PC. for!ttIjifiason"
V TERIAI&
WFWl I cLkw A ji� Bwa
iki4- I
54-212, 64-M
§Ianatil _Ofll�ow�ii�: h
'k�,A
;2�
W,
IM RWOR h,scompE-'NSATION�DEiC"'-'���'
�u I
E
WORKER'S LARATION'; 11" R P
1,• w
-perjury one tof the! following, declarations: - 'CITY(IFLAQUINTA-
r
zf I� at, rirn,�hder; penalty �Of..
U') < 'A
a6kflc'at'eof consent to s 4surbf6rwork V FIN kNCE DEPT.
1;4 W
P 0 �J hivW �ff n workers'. ALUATIOA
W. I I
LL I . I I r.."!by'SbEtl6'h!3700',of'th'e'Libbi for the'
pomperl!at-pn�las prov ded Joi. c66,
0 -J -H ki 066�_
:3
O. , <A I performance work for whic it is SSU86.
_3 , .., , �;_ -
co '. (.1), 1 Have and 'will. maintain'. workers' compensation insurance, eus required I*
+
S I the Libbi C6de r. "performance a
-ecIllon 3700 0 My w6rj�." Jo tKi", rlo i66e� bf, S ivprk forJVhicfi,this
pe compensation, InSdirahce,carrier,& policy.no' are: -v
rmd js';issue
Cartier, Z q: d
ESTOUTED CO9r arm-li-moliq
STATE MWD OF C014
� �', 1 1 _ , 1 14 � - 1, � r , - V, . T r 2- S - - I -
14 111� in g,
$100.00 or less).
PKIWr 304ARY
y,',(This 'sedon need -not be completed "the permit valuaiion is for
)A certify that in RFR(X)F M 1010.110-418-0(*
n th6 performance of the for Which this permit Is issued,
001t
�wrw k4shall not em;J16�'ariyper;sion in any manner so as to become subject to the
41
compensation laW-S'o'f Califi3mia,jBncl agree that if I should become
subject.to the work&il cornoeAsatidn piovisions of Section 3700 of the Labor
a.0 d I sh liforthhithcomply 'with those prbvis16hs. -
71, t. P., A Aiviii
Date:
yjC�; V A-111-
Warnlng:'Fallure 's! is unlawful and
to secure Workb1rs'.Compensai1bn coverage
'in employir to criminal perialtie'i andcivil fines up to $100,006: in
shall subject
addition to the cost of compoi6iition, dain�ia6i'as provided for in�Section 3706
4 !,Zof the -taborCodii,'�Interestand attorh6y's' fees'.' 4
5
tIM,
2
DIrector of Building and Safeh
Application Is hereby made to the Safety `'IMPORTANT
-for a,permit subject ,to; cbnditloni,Iind 46trlctibns.�sist forth on his
app icat on.,-. .
Each`psrion'tioon whose.behalf thi§ applica"Lt!ion'is iWade.&'each person at
whose request and for,.,whose benefit work Is performed under, or.pursuant to SUB-TOTAT. CO2(' UC AND PLAN CZMM-.,' S30.001-
s6ed 's dresult of this appliciton agrees to, & shall, Inds nify . I . - ..
any'permilt Is a m ISM M -PAID IWO so, 013
& - hold harmless 'th6 tlty Of La Quinta,i Its, officers,, agents and empldyees.
2.Any permit lss'6ed as a,r4iult of this, 'application becomei null and void If
work,P1)UE now SM)KI.-
is -hot commenced 'within 180 days'from date 'of. issuance of such
TOTALKIMMM6
;,perrnit, or cessation oi,ii6rk for 180 days will subject permit to cancellation. •
-
certify that I have,r9ad this application and state that the above lnf (DAimatii3h is
•V4_014. borrect., I ag"ree to'boinoly With all City, and' State. iiws relating to the 'bulldlW,
construction, and hereby authorize representatives of this City to enter L upon
n,
i
ATE y RECEIPT D BY _1iN"R
the above-mentioned property for Inspection' I -
purposes. E FINALED
%t
A
n re'i Owher/Agent;,,�*nato1,,;,/V`/.,-,-
..........
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