0109-135 (RR)N W
Cy
W
Z
k—uw�
CL
N
Z
0�,
(L —
r'QO
XW—
oOoQ0
a°.'z
00 -1
n0
3�
ISI
,ICU
I hereby affirm under penalty of perjury that I am licensed under provislons of I -
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and LATEProfessionals Code, and my License Is In full force and effect.
License # Llc. Class Exp. Date
770940 69 me 11/30)01
Date Signature of Contractor
OWNER -BUILDER DECLARATION
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,,wlll do the work, and the structure Is not Intended or offered for
sale (Sec. 7044, Business & Professionals Code).
(io 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
Date ! Signature of Owner
_ ..V
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:
CarrierPolicy No.
STA` MHD 285-00-000I3t99
(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
u orkers' 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 sh/all forthwith comply with those provisions.
`
Date: 'r / , 'i / o�"f Applicant '�
'-Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, Interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit Issued as a result of this applicaton agrees to, & shall, indemnity
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permif Issued as a result of this application becomes null and void if
work Is not commenced within 180 days from date of Issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
1 certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) -'lr`� ' a `` " �'/ Date .,,/.
BUILDING PERMIT
j! VALUATION LOT
+� i1 AS/winn
86 -G 79 n�t� T
M
PGA WEfff &'7`1'1TI' L ROM WWNM
P.O. BOX 1060
LA QUDrrA
USE OF PERMIT
TRACT
APN 7
nTRACTOR / DESIGNER / EN41INEER
M,M= RCyOk'd G, JNC,
63.597 M&C n 5'f, ,
IIMIO CA 92201
(160)347.9869 CM40 5978
RZ-ItOOF WITH CLAM A MATERIALS. SLDO 6: 80.623;1 67'➢, �
M674' 101.07
VAIXATION
I,S00.00 LS
Iffrn"M COST OF CC)i'iSMUMON
OOfr FEE 101.000-41$•000 E30.0p
e
SEP 18 2001
CITY OF LA QUINTA
PIMA--
suB-TgTAI. CONbTIItucnoN AM P LM C W. K `a
LIMS PI5PPM 1
FA
TOSW" PERMr>laJ=DIM NOW
BY I DATE FINALED
1,500.110
$30.00
$0.00
$30M
•
INSPECTOR