0109-154 (RR)I hereby affirm under penalty of perjury that I am licensed under provisions of UILUIN IJLKIVII,� d its
,i`t1�''�'fei�j,+<+►'•Y
Chapter 9 (commencing with Section 7000) of •Division 3 of the Business and DATE ell r�.� vALuanoN *4 4 LOT :r ! : �Q.t TRACT t ;
Professionals Code, and my License Is In full4orce and effect. ; ti ,�# y • r t .} f Y ; ;„ rr t �;i�4
LIC9nS6li f ati! i S LfO�i`ilaS3, - Exp. Dat9 ' • ;' �. ,�- R:l'y 3't"' a3'v. f r -'k' j.�'ij:.�Siy
Frj3 •!4� i.a. , =3�./ !s JOB SITE 4 1 .i';•'si. . S• o ".F 2., r.Y ^' P' tlr. APN `"� a 'A
!q. pp S ^ �p� ADDRESS�j�.�Qj� e} 'k.. s t{�} iK"I•• .rAr-�2 ,, F•t',S�l• q4z
709441 , � .0 4•.'��'�1I7V� E �!I?,. C.l /O"• �fU i • 9. s} :'si. '�7x r, �•�-M .{i d T6 f 't�'+,'8 < �ji2„�.
t + OWNER R CONTRACTOR / DESIGNER / ENGINEER
�• t ? '
Date Signatwe of Contractor A d r ,„� T� , f?t, ,4, r�
OWNER -BUILDER DECLARATION ,, sftTl, t tb�`� x l .' y
J
f,• `
PGA f $ItDJEN'i`LRI. �tU®Wldd>�tdi'ViE%1I�D $00I0i(3, INC
hereby affirm under penaltyof perjury rythat) am exempt from the Contractors, I),Or WX l M'-,. t.+'r 3»397 P19AM J�
License Law for the followingreason: ' -. ? ;* ' y
Y P Y 9 y ;
as owner`of the property, or m- em to ees with wa es'as`their sole i.AQYTlN"iA
az f = U�TL)IO •- ,. GA 92201• § ..
h s + r„ CE3.atl5 Sg7 8 x .
compensation; will do the work, and the structure is not intended or off(760)347.9869
{ered'for a`.
s (Sec. 7044, Business & Professionals Code). }'' USE OF PERMIT • * 1
�jO I, as owner of the -property, am, exclusively contracting with licensed ` T • •ri "Ti
co tractors"tol. construct the project (Sec.'7044;' Business & Professionals d(,�UJ.IdIiN(}
Code) _A_
�. '.
Y
() I am.eze' t u er action t 'B&F? C.' for this 'reason ` a �, MRCJ4�Pr'A WITH CL AS'S 'A MA IMALS. BLDG A 34-367,54-M, -
Date-rSignature of Owner -, `f x5343954 D i• Lr=�1; ,k} a
s WORKER'S COMPENSATION DECLARATION '. `• 1
her eb' .affirm under~ anal of e u EP t 8 .200 Uu
y penalty, p 0 ry,one of the'following;declarations:
(' )' I have and `will maintain a certificate of consent to self -insure for workers' `VAL,tfATSUN' L3'
corripensation,-as provided for,by':Secti6n'3700•of the Labor Code,for the
C TY OF LA QUINTA
performance of the work for which this permit is Issued. FINANCE DEPT.
,: () i I have and will • maintain workers' compensation insurance, as required by '
Section 3700 of the Labor Code,, for the performance of the work for which this,
k•,Permit•is Issued.- My workers' compensation, insurance carrier & policy no. are:
PNo:"
+CaRiBf .. t. .r* 0lic y ” F
a . No.
z83 -OD -110Q19 'I `' ISI TED C011T OF �C(?MMf.` OR 1.5M.00 • _.
(This section need not be,completed if the permit valuation is for $100.00 or less).
I certify that in the performance of the work for Which this permit Is issued, RA00F M 1 Qi •�� ! �"� 8�•�
shall not employ any person in•any manner so as to become subject to the'
' workers' compensation laws of Califomia; land agree that if I should become
subject to the workers' compensation provisi ms of Section 3700 of the Labor
Code, 1.shaIl forth ith comply with thoge plovlsions.. /
Date: Applicant 1 ri /1 l / A ✓ r
�• r
Warning: Failure to secure Workers Compensa l� overage is unlawful and r
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 '
i�of the Labor Code, Interest and attorney sfees.
IMPORTANT, Applicatlon Is hereby-made.to the Director of Building and Safety
'for a permit subjects to'thi conditions -and restrictions set forth on his o
application + §+1Yr c �. • t !
-� 1. Each person upon whose behalf this application is made & each person at f
2i whose request and for whose benefit work is performed under or pursuant to $Uia-Tow. CohJB'i"IdUG!<` ow AND PLAN* (mm
i' an permit Issued as a result of.thls a licaton a rens to; & shall; Indemnity
t
.s, Y P PP 9 fY I FSS+ a'MPAM MM $0,00 '
hold harmless the'City of La Qulnfa, Its'offlcers, agents and employees:
±21 Any permit issued as a resultoof this application becomes null and vold if
T+;YrAL � FM LIVE NOW 830A0
work Is not, 6ommenced wlthln'-180'deys from date of Issuance of such ,.
*`,;-permit, or cessation'of•,work for 180 days;wlil subject permit to cancellation. : ' �s*• i.
?'.I certify that l have read this application and state that the `above informatlon is
correct. I agree to comply. with' all City;
and State laws relating to the building
1onstruction,tand'here.by authorize representatives of this City to enter upon 4 t
`.the above mentloned property for Inspection purposes
RECEIPT DATE BY DATE FINALED INSPECTOR
4Signature (Owner/Agent)ki/ '� Date Ir7., -
i' +l ry p w y 2 h ! . F �f .Flsi s' S v 4 ' 7 1 ° h' t't.. i • } + �dti :r..sl
LA t t4�. . r.� � iJ�:'s."'d'k }3i�,-. � r v �<r„� r➢. � 1 ti. 7 ` R { •t.
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