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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 # Uc. Class Exp. Date
77(1140 C39 Hr,
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I IrjAf01
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
ntractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section , B&P.C. for /th�it reason —�—
Date k') r) Signature of Owner Is It
—777,77
r
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 this permit is issued.
( ) 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
permit is issued. My workers' compensation insurance. carrier & policy. no. are:
Cartier Policy No.
S1',ds E FMD 293-00-40019"
(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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: j' ' Applicant—
Warning:
pplicant
O fi
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 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, indemnify
& hold harmless the City of La Quintp, its officers, agents and employees.
2. Any permit Issued as a result of chis 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.
A e, .4 )
Signature (Owner/Agent) u
PERMIT -
PUILDING
DATE VALUATION LOT 01QQ-•137 TRACT
JOB SITE
APN
ADDRESS
SO- OAK,
OWNER
CONTRACTOR / DESIGNER / EN (NEER
PaA wv3.r umiwnAL wmowNm.A
sal mamAai Roopma. mc.
11.0. BOX 1 M
83.597 PEACH Sr,
L#> 0YfIi r,A
1WD10 CA 9x201
(7150)347-"69 COLO 5978
USE OF PERMIT
C1EAlERA1..11I1Z1,7 I NG
RUROCIP WITH Cll .#M A MA.TF.RIAIS• BLMR. 20-631;W64
8044 W613
VA1,UATJ014 1.300.00 La
EgMATPD COST OF CONSTRUCnoN
1.5W:00
FJ3?MfT FEE 9UMMARY
RW1OOF nz .10I -000.418-000 E30.00
7
SEP 18 2001'
CITY OF LA QUINTA
FINANCE DEPT.
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011184 (7'rAL CbMn UCTiQN AND PLA 3 ' ` : t, t
f
x30.00
TOTAL PMW FM DUE NOW
W100
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
Dater". L �• �:.:.