0109-153 (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 Lic. Class Exp. Date
770940
Date
C39mc
Signature of Contractor—
�
BUILDING PERMIT -
DATE.
pg
t . / VALUATION LOT r ' 01.liS� TRACT
�. /! / , �� :may•'' h% 'Ii u7 tw'
JOB SITE c n APN
ADDRESS
OWNER CONTRACTOR / DESIGNER / EN INEER
OWNER -BUILDER DECLARATION PGA RFZD1.1+1'!'1a H 0MLOWt+#M nGVAi:D-ROOle&G.II Ci i
1 hereby affirm under penalhr of perjury that I am exempt from the Contractor's y,O BOX 1060 09,597 gym 8'l;
License Law for the following reason: L.A. Qid]NTA INDIO CA 92201
( ) 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 (760)347'9689 0" 5976
Zse (Sec. 7044, Business & Professionals Code). USE OF PERMIT
I, as owner of the property, am exclusively contracting with • licensed
ntractors to construct the project (Sec.. 7044, Business •& Professionals ctid*,T,i3UIia��iC3 t i,
Code).;
O I am.ex mpt under Section , B&P.C.. for his re a o I RZ RODIFV# TH CLASS A MA'PIIJ AL% BLDG SII: 39.30'1, 34J314,' p
Date C Signature of Owner 't4Z 0 338
WORKER'S COMPENSATION DECLARATION
hereby, affirm under penalty of perjury one of the following declarations:
O I, have and will maintain a certificate of consent to self -Insure for workers' 1TALAIA710N 1,90D,00 11:CI OF LA QUINTA
compensation,' as provided for by Section• 3700 of the Labor Code, for the FI NIANCE DEPT -
per
formance of -the work for which this permit is issued.
(') I have and will maintain workers' compensation Insurance, as required by ,
iSection 3700 of the Labor Code, for the performance of the work for which this
permit is Issued. My workers' compensation insurance carrier & policy no. are:
Cartier Policy No,
STAT1i'WHD i!WDAA 1M COST OF C101g8i'R1Jt:4n0H 1,�►t1A0
(This section need not be completed if the permit valuation is for $100.00 or less). FltRba r R' _ "MARY
( ) I certify that in the performance of the work for which this permit is issued, 1 101-(KXM 1 t° 4*0 S30.00
1 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 3700 of the Labor
Code, I shall forth ith comply with those provisions.
Date:
�Applicant 1 i .•l!
;t, X.1"� ,,,p `,,. , ., 1
Warning: Fallure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000,16
addition to the cost of compensation, damages as provided for In Section 3706
of the Labor Code, Interest and attorney's fees. t,
IMPORTANT Application Is hereby made to the Director of Building and Safety
for a permit subject 'to* the conditions and -'restrictions set forth on his
application.
1. Each person upon whose behalf this application is made at each person at
whose request and for whose benefit work is performed under or pursuant to
SUS-10XAL CCiNRf1$P, t -MON AND PLAN CiiGCK -;; 1910,00
any permit Issued as a resultof this applicaton agrees to, &shall; indemnity
IH PMPA1:DFM $0..OD
& hold harmless the City of La QUinta, Its officers, agents and employees.
'2. Any permit Issued asresuluof this application becomes null.and void If
,a
work Is not commenced within 180 days from date of issuance•of such
WrALMMriSDUS l OW Mao
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 tIoenter. upon
the above-mentioned property for Inspection purposes
. ' RECEIPT
Signature (Owner/Agent) +"r D"XZ-(-xL4 ate_
DATE �• /, BY DATE FINALED INSPECTOR
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