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0109-151 (RR)ntractorsino", construct -11[119, project to c 10"- Business A P rok s n is y %yrZV?SXPJa rw 3l "gN 4-` mexerni f 3 �1-, ,:, - - oi ` !�. XMI P,� �9 S RXROOT"IVITKCJ",� NATRAtl" Mbdii ;-fo �22 R! L --. ..* - - 1­:j�,_, i;�. 7 Signit ­ " - . , �, .71% -O,t T I'M s..-t,ilA,f,OFii(tR"SCOMPENSATION DECLARATION: 100.� rn _'�of;. er'�`ji'eb'a"hy. pprJUr '.df,thbZf6II6WInd-deC In•0 :0. heii4--dn wil maintaKa -I sure rworkers!­ .4 �6ftifi6gWW66sehiti elf 6"1 d' VAWATIO01. W" I hereby affirm under. penalty.,of perjury that 1, am licensed under provisions of• slon' of't- - 'B -Cha pter 9 (commi g With Siciidnlbbb)�,6i 6iivi *,�I` the usneisis',4'n'd. shcln 4*E1U1L01NG,;PERMM­., 1/7 .......... 3 ilg ,,TRACT, N. Uj effect: -::t. f6IJ1`f6rce*andi Professionals Code, arid'my LIcehs6,Is1ntN ' ' - : ' - 4, A, :AA IN- ;' - %.I , : .,�l 11'1�_�1611. , —R NF.e.2f CV) License 6�� Date 't I JOB.SITE. ADDRESS-.. ADC R , ­­ ­ A - — 4 , 1AV, - V�, CY * , 1, -A UJ 77 ti 16--, 1 �, R, OZ. 'JI�Ioffil SighatUre'of"CoW 46tor 'OWNER CONTRACTOR DESIGNER/ FNININFERi 0. 'BUILDER L) DECLARATION oj� �6A Vmr i�E� ROORN0,AN' ,44 -i UJI LU -o �06­ 'I am from'-tei rjury Contractors, I hereby affim�,Wd6r. penalty f that- ­* K, F- M C0 License Law for the f6IIdw*in'g're;BSo`ri`:', LA UOUA t. ism 44, , - ; , 20f. Z i;.asowner;6i�.ihb,.prooii.riy,.or.*"my'e'mpl'o'y'e'es With wages as'lheir,sole' employees 60)34 5978: compensIk�6:41'11.:Idbt the- work ;and K and t 0 strd ure isnot intended dir..olfferidd forte 1_ �s SBusIrf6ds & ProfessionalsCOde) r the`" usyq y. �:' ll'? lo:dadw bl� I contracting with :Ilcensed I USE OF PERMIT' ntractorsino", construct -11[119, project to c 10"- Business A P rok s n is y %yrZV?SXPJa rw 3l "gN 4-` mexerni f 3 �1-, ,:, - - oi ` !�. XMI P,� �9 S RXROOT"IVITKCJ",� NATRAtl" Mbdii ;-fo �22 R! L --. ..* - - 1­:j�,_, i;�. 7 Signit ­ " - . , �, .71% -O,t T I'M s..-t,ilA,f,OFii(tR"SCOMPENSATION DECLARATION: 100.� rn _'�of;. er'�`ji'eb'a"hy. pprJUr '.df,thbZf6II6WInd-deC In•0 :0. heii4--dn wil maintaKa -I sure rworkers!­ .4 �6ftifi6gWW66sehiti elf 6"1 d' VAWATIO01. W" X"Lu. .-,cbmpi3fisatidh,.iis,,proViddd,for by Sectlom3700t.& the -Labor, Code forthe O .tea "V i6rformince',ofthe wo Jor which this pdrihit is issued AArw, ,u s) u, I Have a1n will,paintalny'oB�iiicompensation insurance -as-reqUrdd.by .- O qP866tion`370cf the iCeJorth,e,Peifrm68eoi",WoWfor;wfiich AN S. doMpensatigrijrIs -perm s ssue WAers!� uranow-camer. ',p6iiciy`�nq, are: d.,,My- x" ut M cvgr OF 1.5ooho -�vo STATE 7�_ "7' 3%_',.(ThIs 66domnd6c 'not:be'c ' om ' pleted: if th� a it , Perm 06 66 or 16SS)� V L PIL rM I cdrtity thatll,!h! performance of thevork, or whiihiks 6eimit 'is -issued, , 101_MP-.418,0( f S3p06 a* rel 'ha4'n',oi­tBrnpioy, any. person, inany;manner ;§6'tas t6:6666me'sU,6)66Vto pqqsatiom aWs-of:baIif6mii:,%And'agr6e tha6f I Should become aubject to -6 workers' compensation provisions of Section 3700 of the Labor Code ILs rifican hllfori�vithcomply "��4t6.i6.ieprovisions. 4lican n / C -Y pens "is.unlawful-and . 04 Warning: Fallureto secure W'.ork6`rs-?--o2 in 'Wnal�periaitibs:afid civii,,'firIes. 00,000 `shat( subject�ah,ernplo`y - ek to criminal 0.1. ditl8n to th6,,'-c8St 0 qmpeosatiom damages provided for In Section 17 6 ;ofahis Labor Code interest and afforney.s fees IMPORTANT Appl 16atiA)s..._6eeeby made WM'V Aitector of Building,gnd Safety a' "co"bditions''.rand restrictions set forth on, his h Odr�b-K 1. Esid'Uoonwhdse'behalf'thigio-oii'c'ation ismadb&6ach.persionaf whose request 'and 166 :whose benefit work Is -performed under or pursuant to MM -TOTAL CONTCRUMON AND PLAN MWOC $30.00., any pbrmitilssued asa':resuItofthis "apollcii6n.agr6eitor&shall; *indemnify !'IT. IAM PRF -PAID XMI$0.00,:�.- , City c A: hold iiam iles'S thet if Lidi:,r 'iisofficers J4'gents:and employees. 2:,,Any.permit,I'isuedid6,'a�'ris61t:�'bf:this-applir ation'bec6mds null and Vold If ,commenced within' 180 '6ys,.fro'ri. date �46*f. TOM PY3MM FM VIR NOW issuance of such 0 Perm Jdi, days Will *,subj6ct �Permitlo, cancellation. . ii,.Or ci�dialloh., f , Work 160 I deftifythiit I have read this lioplidation::Andstate that thivabbve Irifoiriiatlo,ri is id �6nipl� with: &I it correct. agr, 1. Ity, and:.Stalb laws rblatin'g to ihdrbufldihg' agree ,to and the're by"Buihodii representatives ofthis-City to enter upon': he aboiie-mentionedi property for. Inspectiomourooses. .;P. 'RECEIPT DATE BY DATE FINALED INSPECTOR a 1`1 a (OWnei/Agefit)' - W. AIZ.t�zr,,4 �IvSEP,�,, i -' CITY .,0FLkQUINTA... FINANCE_DEPT.� X"Lu. .-,cbmpi3fisatidh,.iis,,proViddd,for by Sectlom3700t.& the -Labor, Code forthe O .tea "V i6rformince',ofthe wo Jor which this pdrihit is issued AArw, ,u s) u, I Have a1n will,paintalny'oB�iiicompensation insurance -as-reqUrdd.by .- O qP866tion`370cf the iCeJorth,e,Peifrm68eoi",WoWfor;wfiich AN S. doMpensatigrijrIs -perm s ssue WAers!� uranow-camer. ',p6iiciy`�nq, are: d.,,My- x" ut M cvgr OF 1.5ooho -�vo STATE 7�_ "7' 3%_',.(ThIs 66domnd6c 'not:be'c ' om ' pleted: if th� a it , Perm 06 66 or 16SS)� V L PIL rM I cdrtity thatll,!h! performance of thevork, or whiihiks 6eimit 'is -issued, , 101_MP-.418,0( f S3p06 a* rel 'ha4'n',oi­tBrnpioy, any. person, inany;manner ;§6'tas t6:6666me'sU,6)66Vto pqqsatiom aWs-of:baIif6mii:,%And'agr6e tha6f I Should become aubject to -6 workers' compensation provisions of Section 3700 of the Labor Code ILs rifican hllfori�vithcomply "��4t6.i6.ieprovisions. 4lican n / C -Y pens "is.unlawful-and . 04 Warning: Fallureto secure W'.ork6`rs-?--o2 in 'Wnal�periaitibs:afid civii,,'firIes. 00,000 `shat( subject�ah,ernplo`y - ek to criminal 0.1. ditl8n to th6,,'-c8St 0 qmpeosatiom damages provided for In Section 17 6 ;ofahis Labor Code interest and afforney.s fees IMPORTANT Appl 16atiA)s..._6eeeby made WM'V Aitector of Building,gnd Safety a' "co"bditions''.rand restrictions set forth on, his h Odr�b-K 1. Esid'Uoonwhdse'behalf'thigio-oii'c'ation ismadb&6ach.persionaf whose request 'and 166 :whose benefit work Is -performed under or pursuant to MM -TOTAL CONTCRUMON AND PLAN MWOC $30.00., any pbrmitilssued asa':resuItofthis "apollcii6n.agr6eitor&shall; *indemnify !'IT. IAM PRF -PAID XMI$0.00,:�.- , City c A: hold iiam iles'S thet if Lidi:,r 'iisofficers J4'gents:and employees. 2:,,Any.permit,I'isuedid6,'a�'ris61t:�'bf:this-applir ation'bec6mds null and Vold If ,commenced within' 180 '6ys,.fro'ri. date �46*f. TOM PY3MM FM VIR NOW issuance of such 0 Perm Jdi, days Will *,subj6ct �Permitlo, cancellation. . ii,.Or ci�dialloh., f , Work 160 I deftifythiit I have read this lioplidation::Andstate that thivabbve Irifoiriiatlo,ri is id �6nipl� with: &I it correct. agr, 1. Ity, and:.Stalb laws rblatin'g to ihdrbufldihg' agree ,to and the're by"Buihodii representatives ofthis-City to enter upon': he aboiie-mentionedi property for. Inspectiomourooses. .;P. 'RECEIPT DATE BY DATE FINALED INSPECTOR a 1`1 a (OWnei/Agefit)' - W. AIZ.t�zr,,4