0109-136 (RR)I hereby affirm under penalty of perjury that 1 am licensed under provisions of
FN- 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.
C 5 Cn License # LIC. Class Exp. Date
LLJ T-
770940 C39 me 1 1130m
Z r- Date Signature of Contractor
m0.�
J U CID OWNER -BUILDER DECLARATION ,
H a I hereby affirm under penalty of perjury that I am exempt from the Contractor's
N License Law for the following reason:
Z ( ) 1, 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).
('6 I, as owner of the property, am exclusively, contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
�
O lam axe pt nder Section B&P.C. ,for,• is reason
Date / ' Signature of Owner , lc'.:i L�
U IL — WORKER'S COMPENSATION DECLARATION
o Q I hereby affirm under penalty of perjur cone of the following declarations:
U') FQ-. O () 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� Q performance of the work for which this permit is issued. .
I have and will maintain workers' compensation Insurance, as required by
O U QSection 3700 of the Labor Code, for the performance of the work for which this
n. permit
permit Is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
CD
CD STATE MD 281-40-R44M
(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,
P'11' 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, Ls all forjhwith comply with those pr visions'.
Date: '' Applicant-'—� 7 d tom% /
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, indemnity
& hold harmless, the City of La Ouinta, Its officers, agents and employees.
'2. Any permifissued 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 certity 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 inspection purposeA.
Signature (Owner/Agent) ?'���I' •� (` Date
DATE Z
VALUATION LOT �, �`;�1n�'i�TRACT�
1.
JOB SITE
APN
ADDRESS a ti
o -b . OAx
OWNER
CONTRACTOR/DESIGNER/EN INEER v-
PGA MR Rl)FMM HIOWOVItNMI
DIM= P.WFWG, WC
V,0. Box 1060
83.597 P ACH B!'.
LA QUWA
WDIO CA 92201
(76V47•9W9 C 5976
USE OF PERMIT
GEIMPI. BULLDWO
RXR(7f39 WrM CLASS A MATIMIALS• BLIP? fIM54 80.649,
84.643, 64^6 ,
VALUATION I,s4o.oD IA
Iffrn"M cour or CONST1 IUMON
1151XAO
Wr Fn NUMNtY
RnOOF 1F 101.000.418.00U $34.44
4.
SEP. 18 2001
C
FINANCE QUINTA
DEPT.
86046 L CONU i1MON AND PI �J ,: � �
�J O.QO
M3 PROS nW
5000
'I'UrT111G PST P711 D NOW
$30.00
/
RECEIPT
DATEBY
DATE FINALED
INSPECTOR
f r/ f.