0109-134 (RR)U)
I hereby affirm under penalty of perjury that) am licensed under provisions of
F— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
D Cn License # Uc. Class Exp. Date
w
CC
t
7740 C39MC ! 1/30/01
cZODate f%�f�'r' l Signature of Contractor
or
r S
F-' OWNER -BUILDER DECLARATION
Ha rl_ I hereby affirm under penalty of perjury that I -am exempt from the Contractor's
CO) 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
ontractors to construct . the project (Sec. 7044, Business & Professionals
Code).
�' () I am ex mpt'under Section , B&RC, f is ea�°n
O N Date �� :ii,+ � 6- Signature of Owner'', ���1,� t�.� .' �.
d .Q WORKER'S COMPENSATION DECLARATION
QI hereby affirm under penalty of perjury one of the following declarations:
r H O () 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.
CO Q U ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor_ Code, for the performance of the work for which this
tl LO Z permit is issued. My workers' compensation Insurance carver & policy no. are:
'T =) Cartier 'Policy No.
00 IITATl!?'�U1d10 2ilS•00.0001997
g (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
j4tDaite:
ode, I shall forthwith comply with those rovisions1/ L Applicant (arning: Failure to secure Workers' Compensation coverage is unlawful and
all subject an employer to criminal penalties and civil fines up to $100,000, in
dition to the cost of compensation, damages as provided for in Section 3706
the Labor Code, Interest and attorney's fees.
MPORTANT Application is hereby made to the Director of Building and Safety
I for a. permit subject to the conditions and restrictions set forth on his
application.
t 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.
12. Any permit'issued as a result of this application becomes null and void if
work is not commenced wit hln 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
r IInspection purposes.' s
r'' • Signature (Owner/Agent) °j •�` (; t Date+''7/� �' =n'
BUILDING PERMIT-,-,
DATE' i j/ VALUATION . LOT , 0 134 TRACT
o
JOB SITE
APN
ADDRESSp
p
O -(09/
Q �j /, y
s
ry
OWNER
CONTRACTOR / DESIGNER / EN INEER • i
PGA WM MMENML H0MiMiNNF.I *
62 F.rMO" R00MG, INC: '
P101130X X060
83.597 PPS OT. ;
LA QU1>!id'A
DW10 CA 922101
(160)347.9669 (MLft 5976
USE OF PERMIT
0ENERAL IIUMMG
]!t&ROOt3 VnT1 ,.CLAM A MATZRLALS- HLDC S: 30.709, M701
804$97, mol
VALUATION 1,300:001,3
991MKATED COU 0F CORMUCTION
115W.00
PE&a-Wr. i M 911MURY
REROOF F1 r 101 -WO-41$-000 $30,00
' T
D°
SEP 18 2001
CITY OF LA QUINTA
FINANCE DEPT.
'
!t
WS -TOTAL CONSTRYIMON AND PLAN CW= :
$30.00
JIM PRE-r'Am pm
30.00
IWAL PEfflfff.IPS DATE NOW
RECEIPT
DATE
`/ I' i .
BY
DATE FINALED
INSPECTOR
�' P..—^ �_�',.�....1; �.�. �a._rr .r_—..._.r.....r.•l�ee.!!6..Y. 4.wr. �..a. �.au. _..� J_2t....•.n.�ru�='.�I.