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0109-155 (RR)LICENSED CONTRACTOR DECLARATION 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 7094.0 <.,35+ 141.0 Date Signature of Contractor OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason: ( ) 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, sale (Sec. 7044, Business & Professionals. Code). ( � I, as owner of the property,;am exclusively contracting with licensed c6ntractoes to construct the project (Sec. 7044, Business & Professionals Code)... O I am exempt under Section B&P.C. for this reason �T Date '? t Signature of Owner. WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty. of perjury one of the following declarations: ( ) I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which thispermit'is issued. { ) I have and will maintain workers' compensation insurance, as required by .Section 3700 of the Labor Code, for the performance of thb�work for which this permit is Issued. My 'workers' compensation insurance carrier '&, policy no. are; Carrier Policy No. 2TATE FkJJ(1431 �i'+ (`ti)•tiSs�? X9;1'"� (This section need not be completed if the permit valuation is for $100.00 or less). O I certify that in the performance of the work for which this permit is issued, 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 forthwith comply with4hose provisions. s ' Date Applicant Warn 146: Failure to secure WorkersCompensation coverage is unlawful and shall subject an employer to criminal, penalties and civil fines. up to $100,000i in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees: 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 & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnity & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such 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 to enter upon the above-mentioned property for inspection purposes. Signature (Owner/Agent) ,!•' ` r/ Date ' PERMIT JI BUILDING .PERMIT DATE VALUATION LOT TRACT k' JOB SITE VADDRESS TAPN OWNER CONTRACTOR / DESIGNER / EN JNEER ^ . , ,w fXY.WF,0VJNERE SS F ZAL-1► ROOPiN6, INC:: 1 � P 0 Fir.> i 06034,55�"/ 1j1�la'Ci ;. LA Qj� r.t:OTA tAC,1�Tc:► CA. 922 p; 0)347 9 Cs�,'_ , t C'EZ,�a INS, '�B A USE OF PERMIT 5. N�liI �,]d �r�tl J:.•�'t..'�L.+. �.i>�.L�.�i7�,7�r ©. : fif;-.h,CalN'Jd'!'1'If LL iaS MAT1�121d4➢.,S➢BL.JDl1�1! 5�2ti�id, 54.436,," — E �i46<<fur 9`s3 SEP 1 8. 2UU1; y ; E:- �•, Ir a �� }�CI qI F.LA.QUINTA FIRI ONCE' Dl=PT.-";,F VALUATION f, 51141, DO 1.9 t } . 1`.�t�JfA.1' 'D r:tJf' 't)Rf CC3�1�'1'1� UC71TnPl Y,'StfA.QiA t, ft l t l'.tf 4/F• (.; i'0 1 -000-4 t 8-000 00 x `.Y r:{Tlt.� '➢.Y)::AI., cr)1l�1 i�ilc_rTli3� tUdl) �'l�.At� C`kL�CTti < • �3c1A.M A.M. 1XX; ME -•PAU) rilm. s.46.60 lip TUM. PuF now 09100 L a / RECEIPT DATE / BY DATE FINALED INSPECTOR zee