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0109-152 (RR)I hereby affirm under penalty.of perjury that,1 am.licensed under, provisions of f- Chapter 9 (commencing with Section 7000) Division 3 of,the Business and' N W Professionals Code, and my Ucense is'in full force'and effect.' iii < Y C License # Lic`Class :. E Date a ti ►� 770940 Y C39mc Z I-- Date Signature of;Contractor• °_ = ... co J U Q OWNER BUILDER DECLARATION ` ' H WW I hereby affirm uoder;penalty of perjury. that I am exempt from the Contractors,,, CL License Law for the.following reason Z ( ) I, as owTI of the property, or,my.employees With' wages as 4heir'sole compensation will do the work, and the structure is not intended or offered for s (Sec. 7044 Business 8 Professionals Code) y I;,. as owner of; the property,. am extl6slV61y% ritra a' It n? _ wdh_1censed :contractors .to. construct the, project (Sec: 7044; Business. r Professionals Code). r r . (i) I am ex m tinder Section - �r .88P for his reason Date d •Signature of Owrer r a Q 7 � WORKER'S'COMPENSATION DECLARATION ' `. C), a -Z ,CC1- hereby; afflrm Yunder penalty, ofiperjury, one -of the fdllowmg, declarationsr • p.O I have and willmafntain a certiUcate;of consent to self -insure for workers' .., X W, �compensatlon es providedifor by Sectionr3700+'of the ,Labor. Code, for the J `Q performance of the work for which this permit isissued Q •UF �( ) I have 47 and will rs maintain worke' compensation insurance as required by QQ 'Section:,3700 of the Labor:Code-.for the performance of the:work for4hich this {3 permit is Issued My workers compensation' insurarioe tamer & policy no are:' _ Cartier Policy No r u'rAT� tix 3ss.aa ol�o>II► FZa i�,A tg�§ ,�,(Thfs section need not be completed•rf tlle,.p6mlit_valuaUon isfor$100:OO,or less). " certityahat in the performance.of the work for which this,permit is'issued, F` a I shall not employ any person . in any manner so :as to beconle subject to the workers' `compensation. laws :of Califomla; .and agree that if I should become Subject to the workers compensation provisions; of Section 37O of. the Labor Code .I.,Sh 'II,J o� with comply with those pr' visiont. Date- T�kj Applicant r arning: Failure:to secure Workers' Compensation coverage is unlawful and ` shall subject an employer to criminal Or 1�;addition'to the cost of ensation di comp c }of the Labor Code; Interest and attomef a� IMPORTANT Application(is herebyimai y for a, -permit sutiject to :`the' ;conditio application %,t. t ,Each persoh;upon whose behalf th 41 whose request'and for whose benefit $ T -7" any.'perm(t Issued as a resultbf:this i c i t&'hold harmless the City of La Quin 2s'Any permit Issued asia result of It Work'Is not commencetl wlthlnt180 • `ii permit; or cessation of work for f 80' '�,hcertifythat I have read -this application . - ::�?., t-,:....e..,-i:e...ee •;•.......,.,iF,.,.e�ti=e`u Citi,; 4 , the above mentioned proper) Signature (Ownei/Agent)i _i� r,�IA`,rj a�i�,d6y� {�r�.i__.' •L�3�..:r .......Fit.^:':. Aties'and civil fines up to'$100;000,-in, iageIs as -provided for in Section 3706 fees a :� i. td,the Director of Building'and Safety }:and restrictions set.fortFi`.on his .application is made :eacf ,person at ork Is performed under or pursuant to plicaton agrees to, '& shall,• indemnify ltsrofficers agents `and employees. ;application becomes null and void•If lays'from date of iissuance of :such . rywill subject permit to cancellation: . rid stat:uhat the°above Informatlori is ` rid State :laws,relating to'the building isentatives`of•`this City to enter, upon fon purpoJjl Z! sed ;X_ 13 a 1i j} " _ � DATE g, VALUATION fit t. 3t •yLOT :, i. A•O�i(y¢jg�.f,.. ,TRACT i •U [. y f• r+•. TaYt<"t,a.. _f". �7.h '31.;«:�?r.^.,.�..0 ev._,f.,-t.:', E S 43.E»% i�' jog ADDR1,AP!VAKTIM rn-'r It K= : • :. It . 47 dk OWNER • f. - `�' � 4 .a^ '� CONTRACTOR/ DESIGNER /;EN INEER F moo• � ~K..j',« 44 I; .: . ' ,. F�� �s•r'N l'� PGA V)Mt' it8 1D H4Mb:U B ` lkb&hINC" P:t).yCq�3gCrp10�0K B�3�-�ST71' f�i1' MD1.O�,.� � - ::,". �..Jti.�••3F/R,.Yi��i.• ail. 060)347 <; USE OF PERMIT -itY�� WL RUOF WITH1 CLASS I4 MATERIALS• BIZO 21: 54•2zi Si�33dy '� `$4 ?A4; 944.2.., VALUATION 1,300.00 L9 SEP I CITY OF LA C. . _ z a FIMANC OE.'r JRL oov Me 101-000-419-000 -000 i30, 00' .. ;, , ..- BU_ a40T-AL CONY RUM0.9 AND PLAN CUKK f . $30.0V., .�fi.9f9 PSB*PAID.FI ' ' . mob ; TOMair DUE �tDW ' r} _ µ Wow! RECEIPT DATE BY DATE FINALED INSPECTOR / �� a