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