0109-135 (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 grid
N W Professionals Code, and my License Is In full force and effect.
C W) License # Llc. Class Exp. Date
d
= r'-. 770940 C39 WC 11/30/01
ZO Date Signature of Contractor
J V OWNER -BUILDER DECLARATION
W I hereby affirm under penalty of perjury that I am exempt from the Contractors
N 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
c ntractore to construct the project (Sec. 7044, Business & Professionals
Code)..
( ) I am exempt under Section , B&P.C. for this reason
O Date = Signature of Owner '` J f /•
CL WORKER'S COMPENSATION DECLARATION
o Q 1 hereby affirm under penalty of perjury one of the following declarations:
Lo H p () 1 have and will maintain a certificate of consent to self -Insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is Issued.
m Q () ( ) I have and will maintain workers' compensation insurance, as required_ by
Q U Q Section 3700 of the Labor Code, for the performance of the work for which this
d to i._permit is Issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier ",. Policy No.
CD O STATE MI) X85 GS 0t�11497
g (chis 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,
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
3 ; Code, I shall forthwith comply with those. provisions.
Date: I IL. I Applicant
'-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 Quinta, its officers, agents and employees.
2. Any permit Issued a6 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.
t Signature�(Owner/Agent) j��'� d,TI_ r Date `�
BUILDING PERMIT -
DATEm J VALUATION .. LOT01WI35 TRACT
JOB SITE �--^
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN INEER
1GA'WF.7f PJMKNUAL KOMI OWIRI RB
MAIMAW $OOMIG, INC.
P.O. LOX I ow
83-597 PEACH Ur,
`
LA QtTNTA
INDIO CA
92201
(760)34'1.4869 CBLO
5978
USE OF PERMIT
C�1�1t/i,I, i3UI[.UINC�
RE -ROOK' MiTH CLASS A .M MATERIALS. BLIDO 6: 80.6$3, 80.679,
t�-dT.� 1�0-6b? '•
V'AU)ATION 1,500.00 LS
19MATED COST Olf COPiS•rRIIG''iTON
11500. 310
PKR.K" FEE SIM""Ry.
REROOF i 1011-000-418-000 E.3tt.Ofi
• D Q p
SEP 18 2001
CITY OF LA QU1NTA
FINANCE DEPT.
MIB-1O'lEAI, CO2 STRUMON AM PLAN't9wK'.
$30.00
LMS P'.R -PAiD FM
$0,0o.
TOTAL PAT+MM FEEN DUE NOW
00,00
RECEIPT
DATE
BY
DATE FINAL ED
INSPECTOR