Loading...
0109-153 (RR)to I hereby affirm under penalty of perjurythat I am;licensed under provisions of ... UILUING •PERMI7,� :. r i- Chapter 9 (commencing with Section 7000) of. Divislon 3 .of the Business and DATE. �,:. VALUATION LOT f ti +ywTRAcr :. 0109yi� N Professionals Code and, my Ucense isinfull.force and effect: t MS yN; j License # Lk Class Exp Date k ' IO JOB SITELU �. .<*`Si'4a t s`ai:•:" c a u y it%tuQt,; ��i '. / .A$PN ADDRSS 790840 0 AAp•J8 WNER CONTRACTOR7DESIGNERI N Itri?EsY ERZ � Date Snatureof Contractor O JN a^ (p0'� viw �. I— OWNER BUILDER DECLARATION ' F,_ . < .3t. k '• a ; .J U '. ' • IKEA Wim' T I d7Ai. HONMWN1�2S' .�3 Khow RWIGGIC% aW 1 hereby affirm under penalty of perjurythat I am exempt from the Co ntractor's i i'.A, bO 106W ST, LicenseLaw for the ( following reason f " `; )Lg ajxA AdDIG i GA 9a�01 Z ) 1, .as owner; of the,property; or my emth; w ployees wiages as their sole 7 ry compensation; wll•f do:the-work; and the structurets,not intended proffered for 0'00')3+7 -meq CB110 5978' S e SBC. 7044?BUSIn988 & Professionals -,:'.. a "' USE OF PERMIT ( r ). i 1 as owner, of the'prope_ y; am;excluslvely contracting with licensed ntracfors to construct the ^project(Sec,7044; Busine'ss�&Professionals ( ;AJ,j)UjWW()''' r °, am ex mpt u der:Section" °B&i? C:. for this rea n 3 I2C(?R WITH QLetn'i`11HfbTTItdRI.3�,iDA LA:: 34.30Z, 34'-314, p f Date'. .. }: Signature. of Owner b ' S4 � 3ti4-33� CD �""' a: Q WORKERS. COMPENSATIOIDECLARATION hereby.'affirm:underpenalty4of :perjury ones fthefollowingrdeclarationsi S':: ' •y ; . 'I have and.will maintain a certlflcate:of consent toself insure forworkers' 1- O O �IAI.t)A,710N`' ,' 1.00 0@ 1� C OF LA QUINTA X, W ,�' ' compensatlon;'as provided=for� by, Sectlon 3700. of the Labor Code for`the t FI APICP DEPT. ` O =�` vperformance of the workfor ivhlch this permit Is Issued „ A. J 'Q rn Q `V (y) I have and':wlll maintain workers' compensation Insurance as required by 4L r •� Q tJ :Q Secgon`3700 of the I�bor,Code . for the performance of the; work for'.which this a , Q F— , permit is: issued My workers'; compensation Insurance tamer<& policy no.,, are; @: z; Policy No .. a iA96I N@ I b"I'1� B C05T ©lEr` G'ON9mil °TxO1V 1�' 1.f�0 r+z, ,� t-f;�' R *(This sectioneed not be completed rf the permit valuation is'f&'$106.00-'or less):'_ �p ; (••,) 1, certify that in the'performance of the work<for;whlch this permlYls Issued;;. ',I,shall not.employany person in.any manner so.as to become subjectito r F tivorkers' compensationaaws of Gallfornia and tigree that if `i'should become ;'subjecrfo the workers'-compensatlon provisions of Sectlon'3100 1 `the,Labor' 3 x� °.Code,' I:shall forth ith comply with:those piovlslons' Y� Date r APPlicant :+ , Y 11 „ * Warnings Failure to secure Wo'rke� ' Compensation coverage is unlawful and i8hall subject an employer•to•crlr iinal penalties and civil fines ,up,to $100,000, iri•' ... , . .j�addition;to the Cost'- ost of compensation, d@mages as,proyided forin;Section 3706 �,of the tabor Code; Interest and attomeyys fees ktr ,i<�IMPORTANT Application4s'herebymadeao the;Dlrector of13ullding and Safety , • x�,i a for a permit subject *to- 'the conditions ;and' restrictions `set forth on `hi§ � application •'f t YT' +-y+t5N`+` ice•... �, 1 Each person upon,whose behalf this: application Is made" 8 each person at,� # fi• whose request;and tor' whose benefit:worl ds:performed under or pursuant to @�Ci!`3-3'O'I'�L. G°O�J�`f`RVt71TON At�A PLAN $30:00 V. }any permit issued as a' ,result ofFthis appllceton agrees'to; 8 shall; ndemnify t q„ PRE -PAW pig , $0.00 Cig hold harmless�the City of La;Quinta;,Its officers,:agents and employees; ` ° 2 Anypermit;lssued as'a result'of thls-application becomes null and void If '? s work.;is not commencedx Wlthini180 " ays ,from, date of Issuance •of °such 'PAS �I+� 1'ih"�6 DUE Ig01f4i > '.r a , permit,°or cassation of work for 180,days will subject permit to.cancellation. ,r a `' • • t � I certIty that I have read>this application and state that the;dbove information is • q"correct s•L.agree`;to complY;wlth all City and: State laws. relating to -the building -: construction and hereb $authorize r`e resentatives Of chis -Ci to enter. u on Y _ P tY P the above mentioned property for inspection purposes pia} v, ��� s r r/ RECEIPT DATE / BY DATE FINALED INSPECTOR Rr4L;F c Signature} (Owner/Agent) Date�,A/? e * s K f > X3�-rr•��` �, •w ' e��'* r r ,sS . �� p' ,�St`a�.at�y �,r,,y,`„ �,�t '�: k ` .•: _ I -- . 'r �r r y �. , �. +%t �`i.k �M•��,ctr1. t. p.n�' i u?}h"Y�oW..t6 "''' Y'.��i - tr,_.,a1- �+:'r �. '.i• is i ."y�� s�.3.: