0104-223 (BLDG)LICENSED CONTRACTOR DECLARATION
- 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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
f1:.V3 i /V
Date Signature of Contractor
OWNER -BUILDER DECLARATION
-I hereby affirm under penalty of perjury that'I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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, Business & Professionals
Code).
( ). I am exempt under, Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm undee,penalty. of perjury- one of the :following declarations:
O'1 have and will maintain a°certificate of consent to self -insure for/workers'
compensation, as provided for $y Section 3700 of the Labor Code, for the
performance of the work for which this permit 'is issued -
(.) j .have and•will. mairita&nTwopers' 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.
PJ, 0621704
(This section need not be completed If, ;the permit valuation is for $100.00 or less).
O I'certlfy that in the performance of.the'work for which this permit is, issued,
I shall not employ any- person in any manner.,s_o as .to become subject to the
workerscompensation laws of.'CallfomiA, and agree:;that if I should become
subject.to the. workers'. compensation provisions of Section -3700 of the Labor
Code, I.shall forthwith comply with those provisions.-
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 the1abor Code; interest and attorney's fees.
IMPORTANT, Application is hereby made to the 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
any permit issued as a result of this applicaton agrees to, & shall, indemnity
& hold harmless the City of La Quinti; 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
permit, or cessation of work for 180 days.will subject 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
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT# k-
.0
DATE VALUATION LOT 4fif:S TRACT
JOB SITE
APN
ADDRESS
ag'.
OWNER
CONTRACTOR/DESIGNER/EN &NEER {
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ROUNA BRl C14 . C;A 92075 =
(658)792,•151 cpL `�5,UZ3
i
USE OF PERMIT
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"15.150 �`;:'
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OIfY OF LA QUINIA
FINANCE. DEPT
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE To the best of our knowledge, all of the reported work,-unless.otherwise noted,
substantially complies with approved plans, specifications and' apphcatile sections of. the building codes. This -report- covers
_)he locations of the work inspected only and doe's not constitute: engineenng op►nion or projectcontrol..: I
CERT NO.INSPECTOR NAME
! t Clea
DATE 3 �u L-4 .Zvt� INSPECTOR SIGNATU �` y
INSPE'CTION REPORT
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CERTIFICATION OF. COMPLIANCE To the best of our knowledge, all of the reported work; unless otherwise. noted,
�\substantially`complies with approved `plans; specifications"and applicable sections of the bulding.codes..This report.covers..
the locations of the work.inspected:only and does not con stituteIngmeenng opinion or project control.-
CERT. NO. D 7 3.�a �d INSPEdTR-NAME y,
DATE NATIQ