0109-136 (RR)U) I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
CV W Professionals Code, and my License is in full force and effect.
(7; =) M License # Lic. Class Exp. Date
L1J
770940 C39mc 11/30/01
cZ rr• Date Signature of Contractor
0 C
f" OWNER -BUILDER DECLARATION
aI hereby affirm under penalty of perjury that I am exempt from the Contractor's
N License Law for the following reason:
Z ( ) 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
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
c () I am exe pj u der Section , B&P.C. fqr pis r on —�4'
0 N. Date . � Signature of Owner \ r(�1 �• }r7o i (i
rn
Z WORKER'S COMPENSATION DECLARATION
'It Cc C) cr I hereby affirm under penalty of perjury one of the following declarations:
H p () 1 have and will maintain a certificate of consent to self -insure for workers'
X W LL compensation, as provided for by Secf;on 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
In Q U () I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il rn H- permit is issued. My workers' compensation insurance carrier & policy no. are:
v Z Carrier Policy No.
w a STATZ FUND 2811.00-0k10.19"
g (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,
I 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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shal forth ith comply with those pr visio s.
Date, �> ;Applicant 1 �, �!!
�tI •.
Warning: Failure to secure Workers' 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 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, indemnify
& hold harmless the City of La Quints, 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-mentloned property for ir)spection purpos
Signature (Owner/Agent) ,r '� ``� ' Date / A
WILUINU rtKIVII I
/ /
DATE
% VALUATIO LOT. 01WI36 TRACT
iswao
JOB SITE
ADDRESS
APN
,
& 0AX TR1X
OWNER
CONTRACTOR/DESIGNER/EN (NEER j
PGA WEA RFMMT 4L 1 UIOWM01 A
SO DOMM ROOF. G, INC.
PCO. BOX 1060
83.1597 "AICA n. '
LA Qa• WA
DMIO CA 92201
Q60j347.9M CNA 5978
USE OF PERMIT
(;MERA .BURD7WO
R&P-POF WITH CLAW A MATFAU.AIZ. OLDO 9: 90-607.90-60J,
W3031 0489
VALUATION 11300.00 La
XIMMI .D COST OF CC)T06'TRtDC31011
1, p.Slp
P'�
)Mff FFE B ARRY;
RERODP ME 10) -IDM418.0011 130.00
i7
Q
D �
SEP_ 18 2001
CITY OF LA QUI , TA
FINANCE DCj• ,A
F.
>t
&M -TOTAL CCN�iRt1CTtCON A14D ]PT.AN C�C� ' A.
$1.0.00
limmPIi I'Am
90100
TOTAL FILVMT FM bus ]ROW
MM
RECEIPT
DATE,BY
DATE FINALED
INSPECTOR