0104-218 (BLDG)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
ProfAsionals Code, and my License is -in full force and effect.
License #- Lic. Class Exp. Date
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 &:ProfessionajsCode).
( ) 1, as owner of the property; am exclusively contracting with licensed
contractors-toconstruct the project (Sec. •71)4.4; Business.& Professionals
Code).
O I am exempt under Section 'B&RC: for this reason
Date Signature of., Owner
WORKER'S`COMPENSATION DECLARATION
I 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'
compensation, as .provided - for, by Section 3700 of .the Labor Code, for the
performance ofthe work for. whi h.thlspermlt Is Issued 1
( ) I have,and vAri ri airitain workers compensation. insurance, as required by
Section 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:
Carrier. Policy No. 4
c„Ai: l!'31'ajP.�'1�t i.'i';!' ti:?,►r;;:l'��I �.
(This. seci[i* need. not be completed if the,permit valuation is for $100.00 or less)'.
(.) I cerfifythat in the performance of the work for which this permit is issued,
I,shall not. employ,any£person in.<any manner,so as,to become subject to the
workers' compensation';Iaws.of Calrfornla,.and agree, that if`I should become
subject'to the'.workers`` compensation provisions of _Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.: `
Date: Applicant."Y.
Warning: Failure to secure Workers' Compensation, cove rage 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, end;attorney's fees..:. n
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, indemnify
& hold harmless the City of. La Ouinta, 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 forinspectlon purposes.
Signature (Owner/Agent) + Date_
BUILDING PERMIT PERMITp
r
E
DATE VALUATION LOT TRACT
TRACT
!
JOB SITE.
APN
ADDRESS
(')A.K IFIZ 7
-
...
'OWNER
CONTRACTOR/DESIGNER/ENGINEER
J.
Ji�iAPI'37+.1,MJ120C`3A11<;t3'
1.).l�LMAR,€�At i�.lt;C1Pl
CA 92.2:53,
OLA.14AB A.C:i. Cid
92075..”!=�
`851107 92 .1 W)CML# 5823
s .
USE OF PERMIT
t,0CM, OFltll^.3:1%f1�C1RAAd�TEUN!
A�J:It,i` •1."xA�tTI;C1E):i
7.1 `'e T. .t tt'x.
50 j+ `r G,, 3k > A:,t'. +A� 'f .�iiC 1R.ti1? • tiElif IIiTatl .'T"rFj}p u
'
h9C�t.Ctwkl�l.�filTUe`('�fl'..Af..tO6_ti1.1c�A.3'iOPl�
VA,.. MAT] 014 .. 201000.00 1.4
we (.'f;D1'dg.r.f?.vcvI't()t4
20,taD0 00
i%1i:.1'? 10) -000-4 18-000 521t'i.00
:~;'fi;ZCr"td.1MOTION Fft'K-i:.iSilf-) 101-000-2VI 0*
; t:E'.•`:t't)'l�l.. (."10W6. C;"T'i.0N AIN'T) I)L I C1i.101M
$209.00
D/nnlj U T.. IMM P f?Y. Y ATD F7-23
$0.00
7`6
CITY OF LA OUINTA
FINANCE DEPT
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION TYPE
INSPECTION ;REPORT
DLC
HAR�a2�.. A':3� i°c�c;�
�..�ca -'COmE
CERTIFICATION OF-COMPUANCE To the best of oui knowledge, ail of the `reported work, unless_otherwise noted,
�substantlally. complies. with approved plans; specifications and'applicable sections of:the building codes. This report covers
.,Jthe)ocations of the work inspected only and does not constitute -engineering opinion or projectcontrol.'
CERT, NO. D S S9 3 �F f; 5.. 0 INSPECTOR, NAME �` �A S��p
' < " ate. - .. •� ter ( �IYI . , .
{DATE :INSPECTOR
CrTORSIGNATU Qr .
'�.
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