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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`/.,-,- .......... -J