0109-154 (RR)I hereby affirm under penalty of perjury that I am licensed under provisions of <iIL,�.iI�Vu rte �IVII. ,
Imo—
Chapter 9 (commencing with Section 7000 of Division 3 of the Business and 5 ,t, y £r,
P ( g )- DATE I VALUATION LOT c S TRACT
04 W Professionals Codzt
e, and my License is in full force and effect. } ; • • ' ��` >F''�
M License # Lic Class Exp. Date
Q ' €jj,. � 1# .. ' , ADORJOB E
S k,�N
UJ
� '7'?n340 7v° C39W 1113"), 5 37' ,�'OAICTRM
Zr- Date SignatuieofContractor•` OWNER r CONTRACTOR/DESIGNER/EN INEER twg
p +. t ? rt.3 rA.co O } tt f .- OWNER -BUILDER DECLARATIONt �' s�° ' AJ co PGA Wff BN'P AL I•ita OWNI RB I.D ROOI�MO STC � .. ��.k ;
W W I hereby affirm under penalty of perjury that ham exempt from the Contractors Vit; x t "xh ;.. •,',_ `.
I'.t?. BOX 1060`' ':.. 83 39i i'BAL�Ei 4I' �
~ a License Law for the following reason: ; +�' t ' ` a• " k `
� .- g �,e�., °.. • . , t . LA f�U12�T!! <, ;� BiDIO �° , • � r; � .r?{, CA'`�9't201 ' ,
Z - ( ) I, as ownecof the property, or my employees with wages."as their sole •• , `
com ensation,`wlll do the work, and the structure isnot intended or offered for 9.'���"fig I * 597f3
P r•: ,.
S (.Sec. 7044,' Business & Professionals Code). USE OF PERMIT
I, as owner of the property, am -exclusively contracting with, licensed
co tractOrs9.t6,cOnstruCt the proJect;(Sec47Q44; Business &Professionals ': :QEt�IRAL BURDWG
Code):+' ,.trf is. f
()' I a � xe t'u ei j$action `9&PC ff tb 'reason * RP.�RVOY*ITH tv1"AM-d A`UATZMALS.111D } A 54.362, M. r
O Date ,v _ / Signature: of Owner - r„ W77 t SON, 34.39I1
WORKER'S COMPENSATION DECLARATION '' _r • _ I 1 r
Q I hereby affirm under penalty of"peryuryonesof the following declarations: ` EP 1 ZOOI ,
p h (') 1 have and 'Will maintain a certificate of consent to self -insure for•workers' VALUATION h3AD,Sf! Ly.
X W LL• compinsation, as provided'for4by Sectiori 3700- of the. Labor Code;'for the C TY OF LA QUINTA
O J Q 'performance of the work for which tliis permit is issued. • FINANCE DEPT.
a
m Q U O I have and will maintain workers' compensation insurance, as required by
O U Section 3700 of the Labor Code, .for the performance of the work for which this : f
d rnZ • ;'permit is issued: My workers' coinpensation;.lnsurance.carver &•policy no.`are:.' t
a
ITCather , a :'OPolicy No" ;
ano A fly F[9AlA x 28,3 OD-vAal4 '7 IS`IMATED CONT OF COMM=01i n,Spb.QU °
g (This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of thework for which this permit is issued, * RF 101-000-4 19-000 " 13P.0{t ,
I shall not employ any person in any manner so as to become subject to the r
-* workers' compensation laws of Califomiaand•agree that if 1=should become
subject to the workers' compensation provislons of Section 3700 of the Labor ,
Code; I shajil forth ith comply with those pro visions. /s
Date:Applicant ' h 1l' s 1 I A J{
r t ��y., •. ° r
Warning: Failure'to secure Wo4r's' 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 attorneys fees:' dol. ; {, t
.IMPORTANT, Application is"hereby made•to the Director of Building and Safety'
�f for a permit subJect to the .conditionsrand?restrictions s6t.fi rth on his
application
. 1. Each person upon whose behalf thio application is made & each person at
i f 'whose request and for whose benefit work Is pertormed under or pursuant to 803-10TAL CONIMUMON AND PLAN L $30.00
any permit Issued as a result of this applicaton agrees to, & shall, Indemnity - : LW TRE -PAW FM 4D. '
F . & hold harmless the City of La Qulnta,,Its'officers,'agents and `employees, •
2. Any permit Issued as a result. of this application becomes null and vold if
=-.'Work Is not commenced within Igo days'from date of Issuance of such T S'i1I' VM OW • $3i1.i»4;;
permit, or cessetlontof. work for 180 days will subject permit to'cancellation: <: - c '* '�_ r •
G I certify that I hays read thls application and; state'that the above Information is; ' ^'
• f * trcorrect. I agree to comply with all CI and State'laws relating to the'buildin fi t
• r. 9 P y City, .. 9 9
k'construction;_arid hereby authorize representatives of this City to enter upon
the above mentioned property forIn pection purposes..
DATE FINALED INSPEC
} y RECEIPT : DATE T ' / / / BY TOR ,
Signaturev(Owner/Agent) t' 4
-
!Ot
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