0109-154 (RR)I hereby affirm under penalty of pedury,that 1 am licensed under provisions of IJIL:DIIV�i:I'EI MI I=; MOMqi� '.a s > , ; k°'
CO
Chapter 9 (commencing with Sectiona7000 "of Division 3�of'the Business;and / t. s,a"s` '^w
P g ) DATE r `/' VALUATION 07
LOT tiwe ��
C'4,UJ 'Professionals Code, and my License Is in full :force and effect:
C _j cr) license # r UCClass 'Exp. Date,'
JOB SITE
r- Q. ADDRESSOR `. ' i x'< t -C �f� ,�iA Cs• �, _.,,,LLJyt',.
±'1094!?. f •l:,' C39HIG 111SOf01' OAiTRT
Z Date { Signature Of COntrACtOr OWNER CONTRACTOR/DESIGNER/EN WEERf f ! yry h u
co•: OWNER-BUILDER;DECLARATION A�j . '
U PGA WIC i2�lIDB�T ML 1K01MWNM 9 8A /',LD 1l�.C�Oi�'Ddt;�;1>NC
W W 1 hereby -affirm' under enal of e u that I.am exempt from the Contractor's s '
P ty p d ry p i',C;1 ] Ufi0 1�3 s97 PlCfi's4T
N License Law tor;the following reason : ` : Y:f1 fUlli�A iAITDIO CA
Z ( ) I; as owner, of the'property;'or my employees withwages as their sole
compensatlon,4iilfdo the work; and the Structure is not intended or offered for ('±80)3':7.8869 G'BL41f ,.59718
S (Seo. 70441± Business & Professionals Code).; use of PERMIT :.
as owner. of thea roe . ;Sam ezclusivel-contractin wlth;'iicensed
co tractorsRto construct the project (Sec:,7044 .Business'& Professionals 1 diOjk�ALBI)ILDING
s
. , cCode) `
'•. �. }a+, .. .:.;, S'S+!..TF. sf.'41J,`1. k\' nF!• �• ;: h: ' e y::••l. `•� nl T `4 � 14 •i: -y,;.
t •(, �I am axe to er, eC11on. FwRff-;B&PC.fo ,•tb 3reason� , RPeItOQ�'i9F1i9t,CL.ASti A bAA til.At] Z4 Y63, 5974,
j
- sy!.; )r1 .3i: •? 2' ',� _ � �.Y +. s
,, a)ate3 sC' c
Sign ownerA— '�. $4.336 94a393 ," � � �.f•; , s. ;
f"..
WORKER'S "COMPENSATIONDEC.LARATION
a a t .P' 1.T,_i f t 1
EP "1,8' 2001
o [DO
2:,�Irhereby affirm�;under penalty'ofperyuryone of the following declarations: ry
Q I have and will maintain a certificate of,consentto"self-Insure 7,,''f
oEworker,' i} J
r, F�-'. O.(r;) ,__.• ..., . ,, ., x - 1/.A.I.lif1Y1:02i .. �•' 1,SbD OD "� r '-
f compensation, as, rovlded for b Section:,3700 of: the Labor "Code; for th`e `
X W.P Y- d. CTYOFLAQUINTMr
OM J ;J 14performance of tli'e work for which this permit is Issued' • t FINANCE DEPT.
-) . t have an; '111 jrirainIworkers compensation' Insurance as bira(by
O U•,
rn`Q."Section 3700 of:the Labor Code forrthe performance of the ;work for:whlch.this ;
t
a.•o F— nnft is issuedi_fvly workers' compensation -Insurance tamer,& policy no are: Y
Z n°a;Carrler� ' ig =Policy No , . y
ni= ..; _.
' ry.�, , DAZE i�JA1D �� �� »} � : 283-0tt•D�19�1 gy�,•ry'�•�yyry� �� �/� � • . �S�SgIx`�D CUt�I' oP' �GC?�d8.�'�2'I7i`lIUN
!t^,Jg�S fir dt, i iLJtCl7dlR': Q .�.►L QV�3 T
s"(This section need! hot be completed if the permit valuation is.fo� $100 00 or less). "
certity ''that'll n the`performance of the;work for whlchahis permitis issued, ' Rj40O, F 1 til �UtiQ-�l D 8.01 0 " SAM
,..Xshall not employ any person 6 -any manner"sous.to,become subject•to the
:workers' compensatibn;laws of.Ciiifoimia and agree that if I should become -
T subJect.to the•workers' compensation provsl ms'of Section 3700 of the Labor.
= p Code I sh I fortfi Ith comply with thoee lovlsions. l
®_'.'-Date:.Applicant
; � 4 Warning: Failure -to secure Wo ors' Compensation coverage is untaWful and
a* 3 hall subject an emplo'yerto criminal penalties and civil fines up to $100,000, in
addition to the costof compensation; damages as provided for in Section 3706
'of the Labor Code; Intere§t;and attorney's fees
r, IMPORTANT Application l§ hereby. made to:the Director of Building.and'Safety, _
for 'a permit subject < tot the conditions .and restrictions . set- forth on his a.
application, i
1. Each person.upon whose behalf this application Is made & each person at'
„ Y whose re uest'andfor Whose benefit work is performed under or pursuant to RUB-T(MM, CONUMU :.MW AND 1 j,p�T�' (, �
Q P P S30:gQ .:
any•permit•lssyed as a;re"suit of'this appllcaton agrees to, &shall; indemnify ;�'p g pAp�`p �p �,
& hold harmless the Clty of L i Quinta; Its officer§,.agents,and employees^: .
2. Any permit Issued as;a result.yof this application becomes null and void if ��y�� y� y'�'� �q�/y� SWIM
w�w■ �\
1 u,' .1: T*YrALr PMiY✓�L, A" i j; D1 r1MW .. WUItA/`f
work Is not: commenced .wlthln.180' d We from' date of Issuance, of such
permlt, or cessation of.:work_for.160•days will subject.permit,to'cancellation: •
A I'certlfy'that f have read'.thls application and state that the aboVe {nformation Is
• , Co rect. I agree.to comply-with.all City, and� State- laws relating to the building
Yt. consfructlon, and hereby authorize representatives of this.Cityto enter upon
+,the above mentioned property for In paction purposes
a , RECEIPT - DATE BY - DATE FINALED INSPECTOR .
Signature'°(Owner/Agent)r Date—� r