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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
Professionals Code, and my License is in full force and effect.
License # > Lic. Class Exp. Date
77VAO M9LUC 11/36/01
Date Signature of Contractor i
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
se)e (Sec. 7044, Business & Professionals Code).
I, as owner of the property, am exclusively contracting with licensed
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ntractors-to construct the project (Sec. 7044, Business & Professionals
Code); .
O I arn exe pt u er Section '; B&PC: for t 'Is reason
Date `�. Signature of;Owner t
WORKER'S COMPENSATION DECLARATION
16reby'affirm under penalty of perjury one of the following declarations:.
O 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.
O 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 STATK FUWD Policy No. 28�•00.0Al►1999
(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 3700 of the Labor
Code, I shII forthwith comply with those provisions.
Date: Applicant_ I
i I- Y4
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 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.-Ouinta, 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. 1 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. a
Signature ' (OwnedAgent) ' Date
.0 1LU1NUFLKMJLJ.'.,
DATE" VALUATION LOT TRACT
JOB SITE /
APN
,:
ADDRESS�iis,
Jam'
OAkTkr .
OWNER
CONTRACTOR/DESIGNER/EN (NEER.
PGA WFZf R1�'BIDIIIV'l7AL IIO OW1.
EMARALD RWMW, INC ,
P.O. BOX 1060 .'
81 -SW MAIM .
LA QUINTA
INDIO CA 92201
(760)34""9 CXA 5976
USE OF PERMIT
(#I7t7Ri�AL F3UIL35INC�`
RLfiCRJirWITH CIASSA MATERI[AL& HLD0 a: 5e•194 94•e104,
59.212, 54-
?,Fscp,,
i 8 2001
CITY F LA QUINTA
VALUATION 4"0.00 Le FINANCE DEPT.
ISTI M COST OF CON6�MMON
pSNOr YXX MAWARY
Rr:ROOF FEE 101.OW-418.0110 830,00
gTJE3-i'Ori'AIo GOCC�tIXCJ iO A FLAN (".HCFC $30.00
I.1 PR,R-PAID g0.00
TIAL P=MCf FSS,$ DUE NOW S1�Aq
' I
RECEIPT
DATE
SY
DATE FINALED
INSPECTOR