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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 # Lic. Class Exp. Date
770940 C39 Me .11/30/01
Date Signature of Contractor
OWNER -BUILDER DECLARATION f
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).
U) I, as owner, of the property, am exclusively, contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).;. .
() I am exe pt nder Section B&P.C..for,'t is reason —-
Date 7 ' ! '' Signature of .Ownef� ���.;fJ1Z L'
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one lof the following declarations:
(N) 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:
Carrier Policy No.
' STA'T'E PUNA Z85 -40.04b194?
(This section need not be completed R 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 s all fo hwith comply with those.➢revisions'.
Date: ` �' Applicant d —`T
Jr .
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subjec3 an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, Interest and attorney's fees.
IMPORTANT Application Is hereby made to the Director of Building and Safety
for, a permit subject to the conditions .and restrictions set forth on his
application.
1.,Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work Is performed under or pursuant to
any permit Issued as a result of this applicaton agrees to, & shall, indemnity
` • & hold harmless the City of La Quinta, Its officers, agents and employees.
'2. Any permlt.issued as a result of this application becomes null and void if
work is not Commenced within 180 days from date of Issuance of such ;
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I'have read this application and state that the above information is .
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter,upon.
the above-mentioned property for. inspection purposes. '
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SI nature (Owner/A ent)' t f' �� �• -f' -�f - r Date �..�
WILUINU MKIVll l • K�� F : ,W
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If VALUATION LOT, t + .01WIL34! ,,TRACT'
DATEj/
Y
JOB SITE i
ADDRESS,FO 4r
7 OAK ,
APN
OWNER
CONTRACTOR/DESIGNER/EN INEER 1
PGA WB>'3t' RNDFYiMM. ROMOWNM
MARMD ROOh NG, DIC.'`
P,0. BOX 1060
83.597 P$Am or.
I.AQUDTrA
INDIO CA 9.2201
(760)347.9869 Cl" $976
USE OF PERMIT
R.It.R.fDOP WITH CL MS A IWATIMIA]i BLDG 7. "61% 811.649,
VALUATION 1,500,401.41
I2I7t1"M COSH' Olt' CONS='llat"QC'L'ION
1,9D0.00
Pmwrna1f3MI uky
RVIROOF Fly 101.000.418.000 `' 839,04
SEP 18 1001 „
CITY OF LA QUINTA
FINANCE DEPT.
�
'M'i00WMtTCnOH
l 'Y AND PL'A*
$30.00
" LEXI + 1 DMW
8AOO
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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