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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 # Uc. Class Exp. Date
7709,40 . • C39 MC: 11130/01 '
Data / L'I ? 1 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, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
f.10 I, as owner of the property, am exclusively contracting with licensed
Contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O I am ex mpt:under Section B&P.C, for this reason
Date t p'-' Signature of Ownerter' „ri.l . �_i g,
t 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:
Carrier Policy No.
STATE FUND k 203-0R-0001999
(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
Code, I shall forthwith comply with thpse rovisions.
Date:.1_ 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 Quints, its officers, agents and employees.
2. Any permit 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-mentloned property for Inspection purposes.'
Signature (Owner/Agent)+ +{ yr ' Date
DATE VALUATION LOT, 01W13,4,; ITRACT '
J,
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JOB SITE
APN .
ADDRESS8a
OWNER
CONTRACTOR/DESIGNER/ENGINEER ,
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EMER.AL37 R04PWO, IXC.
P.Q. BOX 1060
83-597 MCMI ST,
LiK QUTAi'I'A
WD10 CA 93201
(7619)347-9669 CRT,# 5978
USE OF PERMIT
0EMALBURDING
MRO�OP WITH CLA33 A UATERI.ALS• BLDG 5: 90.704, 90.74
VALUATION 1,300.00 L8
I1;1+11701'DITTi'P COST O1' CON81'.1d1iMON
115M.00
PR1121b71i`d.' YEE 9111u k"Ry
EI~BOO9' SEE r Z 01- I F3�000 t�0,00
i
SEP 18 2001
CITY OF LA QUINTA
FINANCE DEPT.
'
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tiUB-T+0'P.Ax. CONBTTti)C'PiCJN AND PI.P►N "'
$30.00
A,dI+i 1 PRZ• PAID 1W=
10.00
IWAL xEXOMa DUE NOW
sn"
RECEIPT
DATEBY
DATE FINALED
INSPECTOR