0109-153 (RR)I hereby affirm under penalty of penury that.1 am licensed under provisions of , UIL•DINGRERMIT , �. tr
r ; ��'� F r
I— Chapter 9 (commencing with Section 7006 of Division 3 of the Business and �y +:", a c y * t ."
DATE . I r VALUATION 1sq' `:+tfLOT..X .�. �Q�o� i�► r TRACT t� T;
W Professionals Code, and my License Is in full force and effect. ,.; ws`���t
M ch License # a �1Uc: Class . Exp. Date 7 y :� • i (;.,.� .�
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� t• i . i *: i' JOB SITE' r � i i (kn • si 3►tr t r t ; +�n t ai APN
s ADDRE.SS
iiO�ia p/ D�I1/30101, �+ .A
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Z^ DateSfgnatureofContractor r OWNER ;.1 ����x;jz r` CONTRACTOR/DESIGNER/EN INEER* 5' • r;^ 4 +yid
6 _ i >• i :6 ..++^� '' '�, fr+.`�+ef, f �fl tG �2' @ :ree`7•- w e 'r S;
J �p OWNER -BUILDER DECLARATION I)CWWT ;I�[D10 J ' �F
�.. ?-�.-
W Wd I hereby affirm under penalty of penury that I am exempt from the Contractor's -
License Lsw for the followin reason: P.C?, �O?� lf>60 ,4 %;t 4q; y •�
9 ,...: :? :. , y LA QUINTA r " AdD10 , r , CA 83201 -
Z_ ( ) ' I, as owner of the property, or my employees with, wages astheir'sole
compensation, -will do the work, and the structure is not Intended or offered for 1` . "' Y' (1603 47.88 5978
S e (sec 7044,. Business & Professionals Code). s USE OF PERMIT
I, as�owner of the property, am exclusively. contracting,with;licensed
ntractors to construct the project:(Sec:, ,&
7044, Busiriess,Professionals .,
Code) r °
_( ) I am'ex mpt u der Section ,B&PC. for his rea on =tx'I3�+pitac?1!Wlifi CyrfHW7M1Mpi'p = `
Date `i - + F,AIA3 Z K DO 34.301, .34 414,
Ci + '� Signature of. Owner j !i 3. 32d,S�1.338 _�+�� n 1
�� • S .L., i`rtI'.. 1�2r✓ h, r•., , :•' � .w �} �,, j .. �' S i '`,d. •D S f �,� • f '+^ .� t ,
j WORKER'S COMPENSATION DECLARATION ry
hereby affirm under. penalty of perju ` 'one of the ;followin '}declarations: r i
u� Q " s ry . 9
r. �;p VI(t) I; have and will maintain'a certificate'of consent to self-insure'for`workers' VAL,UA,?!ON 1,3i�.40 1,$
W, I , ,, CI OF LA QUIP
,
X W, �compensatloh, - es provided for; by Section' 3700 of, the Labor Code afor the r
O J,� - FI MANCE DEPT..,_ f
JQ` perfotimance of the work for which,this permit is Issued , -,-
m
<'L) ;.; (') I have and will maintain workers',conipensation insurance as required by • r , . .
O V'Q � Section'3700 of the Labor Code,.,for the performance of the work for which this r3 _.. �fi • '� +`
d H z 'rmft is -issued. Mykers
wor' compensation insurance carrier & policy no are: '
Z pe�* `'BlA1'1t'Uiatb a yPOficy NO. n
ryry + ... � ' "` _ •* �5-011•'OAD149'7 ., �` Eg rWA'�D COST OJ@' CdNl�. Ud*n0T4 1,�ttC1Ap•.
✓ tJ � ° (This section need not be completed ff Ula pemtftwaluation is for $100.00 or less): DSPC M SUMMARY
I certify that in the performance of the work for which this permit is Issued; UROOF W, 101.000.418440 >r30,Op
<a,. I'shall not employ any person in eny,manner so as to become subjectito the
* " workers' compensation laws of, Califomia, and agree that if I should become
subject to the workers' �compensation provisions of Section 3700 of the -Labor Code, I shall forth ith Comply 'with those provisions. I (
/I , _
' Dater Applicant j ! t t / ; 1,
Warning: Failure to secure Worker Compensatlon coverage. is unlawful end'
shall subject an empioyer'to criminal penalties and civil finesup to $100,000,.Iri
*F ' addition to the cost of compensation, damages as provided for In Section 3706
of the Labor Code; Interest and attorney's fees �•, �. r `
ti1 IMPORTANT Application'ls hereby made to the Director of Building and Safety f + _ . ' »� • , - - -_ ,
r x4 .,for a permit subject to`the conditions end `.restrictions set forth on his ++
r +
application.,.',•Y r
1. Each person: upon w o' se Behalf this application Is made & each person at '
whose request and for whose benefit work is performed under or pursuant to .;
HUS-TMAL C4DWM>;Tt;'"lTONAND PL,W CiW= ?, ` >630.00
� Cr
`+ any Permit Issued as`a result'of this applicaton agrees to, & shall; indemnify
s
a,Y
+ ; PAID MW VX00
µ, ,& hold harmless the City of, La'Qulnta;;its'officers,•agents -and employeesfi,
„
' i
f
2. Any permit issued as a reeult'of this applicatlon becomes null and ;void •if_`is
=work
TbTALPK1VWVMDUZH0W.
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not commenced within •180' days, fror» date of; issuance of such
P16
ermit, or cessation of'work for, 80 days will subject permit to cancellation.,
certify that I have•,rei'd•this'application' and state that the above Information is
(, #>
'
con'ect. I agree. to comply with all Clty "and State laws,relating to `the ;building
y
constructlon, a6d,herebyauthorize representatives of this City to enter upon
;
the above mentioned property for inspection purposes
V u ' + � �^ ,1 . � / i r :<f sy a\ .; } e �
q.. LfT
RECEIPT +.
DATE /
BY
DATE FINALEO
INSPECTOR
' � �
��Signature (Owner/Agent) 1 ' _ Date t /,fig
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