0109-152 (RR)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 # • lac. Class Exp. Date
770940 C39 MC, 111.90101
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:
( ) 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
s�►e (Sec. 7044; Business & Professionals Code).
r) 1, as owner of the property, am exclusively contracting with licensed
contractors''to• construct. the project (Sec. 7044, Business & Professionals
Code).. .
( ) 1 am, ex m t rider Section B&P. or tt Is reason
Date ;t / Signatute of Owner'TT IV
1.
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury, one of the -following declarations:
(, )• 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..
V( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the tabor Code, for the performance of the work for which this
permit is Issued. My workers' compensation insurance carrier & policy no. are:
Carrier - Policy No.
IITATE FUND 385.40.000lf►�'8
(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 37 0 of the Labor
Code, 1 sh 11 forpwith comply with those prgvision . J
Date: LZ ZZ J ZA 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 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, indemnify
& hold harmless the City of La Quints, 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 purposa� l'
Signature (Owner/Agent){/ Q �•!.-..� si 0 Date'
OUiLuuvu rtrsiuu i -
DATE VALUATION LOT OIWJ52 TRACT
JOB SITE i
ADDRESS �!�
OAS TIM
APN
�
OWNER
CONTRACTOR / DESIGNER / EN (NEER
i A VV1?il'T R IiJ} iAL HO WJh 9a
10 MdRZ&DROOFM(!, INC. :.. .
P.0.13OX 1060
03.397 PEACH OT
I A QtnNTA
INDIO ` CA 92201
('760)347.91369 MU 9976
f `
USE OF PERMIT
�t
GIIMM ASL. }3UMDINO
R ROOF WITH CLASS A MATERIALS- 8IZO 23: S4 -f*, .ii•33Q�
VALUATION l,SOO.QA W
kcSEP
1gITY
OF LA
FIWANC
Fi)[�'= COt9'I' OF COIif6'=(MON
1,300,E
IBiIt �A3 101.OWN-418.000 130.00
OUR-IMAL CON#iI' MMON AND PLAN C)t
$30.00
LRW PRE -PAW I W
$1100
IDT" Pte!' FTS DUE NOW
$MM
RECEIPT
DATE •..
BY
DATE FINALED
INSPECTOR
M