0109-137 (RR)I hereby affirm under penalty of perjury that I am licensed under provisions of
Fy- ( Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C14w Professionals Code, and my License Is In full force and effect.
C License k LIC. Class Exp. Date'
t W � 1":1
770940 C391w, 11/30101
0Z Date Signature of Contractor {
_J VOWNER-BUILDER DECLARATION
JD t ,,*
W I hereby affirm under penalty of perjury that I am exempt from the Contractor's '
CO 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
ntractore'to construct the project (Sec. 7044, Business, & Professionals
Code). i
O I am exempt under Section , B&P.C. for thi reason
Date • Signature of Owner. : l /7 i` - . 1
WORKER'S COMPENSATION DECLARATION
0: I hereby affirm. under penalty of perjury one of the following -declarations:
In
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
O -J Qperformance of the work for which this permit Is Issued.
m Q () ';'� ( ) 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
a, F- permit Is issued. My workers' compense?Ion insurance carrier & policy. no. are:
Z Cartier Policy No.
OD a 'STATE KWD , 183.Of3-000191
(This section need not be completed If the permit valuation is for $100.00 or less),
r• O I certify that In the performance of the work for,which this permit Is issued,
A'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 shall forthwith comply with those provisions.
,Date: el, r. Applicant—
?f y.t u
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 attomey's fees.
IMPORTANT, Application Is hereby made to the Director of Building and Safety
fora permit subject,to the conditions .and restrictions set forth on his
'application:
1. Each person upon whose behalf this application i made & each person at
whose request and for whose benefit work Is perfof� ed under or pursuant to
r any permit issued as a result of this applicaton agrees to, & shall, indemnify
i & hold harmless the City of La Qulnje, 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.
k 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) / i k' Date t�
-�iy M •:t.. .1 5. r{_....�:. _ - �.tr+_ �:_3:=�•_�,.___. 'iib:
i
.+ .. ,L•.aL n f-� s
DATE VALUATION �,'Yb 4 t H . i LOT ` ` • rl x. 61W 01 TRACT
JOB SITE w s r.t
r
APN
�''+
+•
ADDREBe �D�O „
r r
OWNER # +.
CONTRACTOR/ DESIGNER / ENGINEER g
PGA WEER UMMMAL HOWOWNMA
08 WMAM R0014Mo; nasi: E
P.01 BOX ION
' E3•597 PF.AIMK ST, ,
LAQ:UftY1'A.
INDIO CA 97.201
(750)347.9869 cuo 5976 ;
USE OF PERMIT
(3i;MAX.11t?H YNO '
R&ROOF WIT" CLASS .A. MATER1A13• 'OLD0 X¢ 20.6S1, W64
ff0-81l� >10 613 .
VAIMAT1014 1,300.00 La
;-:
S lAM con OF CAnsTmCnom
1.00
PERM I' FM 9UMbURY
RKROOF IEE .1011-000-418-000 M00
D 1:
SEP 18 2001
CITY OF QUINTA
FINANCE DEPT.
".,TC TAL CbmR enoN AND PI;+ i
$30.00 .
w J.1Ia9 f 83
S1100
"T" P1F=f FM MUM NOW
S"100
RECEIPT
DATE
BY ;
DATE FINALED
INSPECTOR
i� , : 1
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