0109-137 (RR)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
N W Professionals Code, and my License Is In full force and effect.
G dLLI M License k Uc: Class Exp. Date
►� 770940 ' C39 1w, ? 1l3Cid01
d ZO Date Signature of Contractor
V OWNER -BUILDER DECLARATION
H aW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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
c6ntractors to construct' the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section B&P.C. for thl reason
Date f Signature of Owner
p r
CL Q • WORKER'S COMPENSATION DECLARATION
- 2 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 Section 3700 of the Labor Code, for the
m-1 Q performance of the work for which this permit is issued.
I have and will maintain workers' compensation insurance, as required by
p U Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn H permit Is issued. My workers' compensation Insurance carrier & policy no. are:
j Carrier Policy No.
co STATE PIJ140 185-00-00D199i
g . (This section need not be completed it the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
f 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
3 Code, I shall forthwith comply with those provisions.
Date:. Applicant r�iT .. ' i •. aA !'
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 V made & each person at
whose request and for whose benefit work Is perfoted under or pursuant to
any permit Issued as a result of this applicaton agrees to, & shall, indemnity
a & hold harmless the .City of La Qulntp, 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
tpermit, 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,(Owne0gent) ' �¢ — Date
J5UILUING PERMIT
DATE ! VALUATION LOT TRACT ' I
�'
JOB SITE / q
ADDRESSSO OAKT
APN
i
OWNER
CONTRACTOR / DESIGNER / ENGINEER -
FF
;
' ;
PC3A Wi�3'1' �l'3`IAY.IiO�t1EU�i'NI�
,� ... •,,
B,�+II£[tALU �OOI�NO, INO:
r',O, BOx 1060
83.587 F ACR Ur,
LA. Qi;wrA
lWD10 OA 92201
(760)347.9869 CKA 5978
USE OF PERMIT
Gn, TIMAL RIJIM)NO
R&ROOF WITH CIASS A. MATE.R1ALS. RLD0 II: 80.631, M615,
-80.619 81}"613
Y.t 1,111AT1014 1,500,411 LS
F17MATM COST OF CONYMUMOIq
1�A0
Fin? MrrM. I 9UMAURY
1iL+1t00F FEE , " ] O1-rJ1)dw4l S-�0 Moo
a a o
3
SEP 18 2001
CITY OF LA QUINTA
FINANCE DEPT.
we SAI. GbmRt cmom AND P
0o
1V30.0o
�;M
SaID0
,
TMAL PERWr F=1 DUS HOW
MOO
RECEIPT
DATEBY
DATE FINALED
INSPECTOR
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