0014 (BLCK)� Cv ul�Gv
t
P.O. BOX 1504 - LA OUINTA, CALIFORNIA 92253
)tit p.rtaa �bco as, goo 11 .ort no rationomaricee .n la,11D MYS ham 6nr OF
a ' o;; . OIL a wore Iran broa
en susDeed abandoned IN a prow 0,
wD''o,:IRS COUIINSAIIDN DECLARATION ellDy a•.Ins
certnh: zit of sum+ns' Cmmpcnsatbn Inlmznce. 01 a ceneym COPY tar�eol ISr. 3600, Lab C.)
Polbcy No Company ^
D Cend.ro COPY Is IxleDy Iurmstle0 ( ,
Cit r0 lei I cd em•1 Ounly 6unl01np I K:Irpr, 1 a C 'til Gt partmtnl.
0,Y%7_E� Apphtan71
(F
AP .CANT AA E F. MI)
Y7
C[RII{ICIIT[ D [:E MPIION FROM WDRtttI N MSURAIbQ The aactwn real not b carolled A Dr
that
l tp lt5[D COet RACTDRL DEp AMT10N. I tlwaby atiea that l am Icnra.0 un6a prwalaa d ClNptat 11ICo--WM 1p
coy dy in the rQ d tt bat pws
prrM a la ort o In Oat 1 cso a eaorma
that n Int podana
wall i.0ro. 711 1 d Dwyt+.n 1 N the Busness and holeatsers Coll. and my acelee a on hit baa ane *"ad
a t or er Compewhicnsation 0
snMi not emplq arty Arson n arty mwrr eco at to become wDpC b Ra Wakwa' Canpweatem leis d Labtama
anyp In n
[tarts Daae [lC Mumbw
Day Applic"
Cantlattw
Falml TO APPUCAMI: R, stir matmp this Ce lHrcay Of E■wh$-On. YOU should brant subject to the Wwtsn*
Dale
Compensation pwrarae d at LaborLaborCode. Too mutt brtA.Rn oomph .On such pwrarae a this gates stud b
Ce
01vNF a-BUI.O(a DEp ARATItMt I MrWy an■a that I am armee boom the Camsaa'a license lar la the totb.■p
tenon f..c MIS Fu unes aro latolessyuns Code: Arty city a county which tewwe a pwmd to tDrmtlrrtl. elm•
deemed revotsd ,
pnsbw of INDtISI1uAl SAFETY RRMrt CER11FlUl lux •' '
' .npowt, drmdoh a Cepa. any shtactute. peror to tie iswanci oho redition the repptyunt to such permit to IM a
that M a tcertsed pursuant to the picho ons of Ire Conlnclols lel versa law (Chapter g lco.mnortp
hretry cettrly Iha1 no eturalron Ives (5) a male IMM 6ratllr into which a person b rpu:a610 6nrsrld. r0 b
s tlDI
(1 1dt this thild "' buft structure.
signed atatrnyer0
Section no d Durnuon I of Dir business aro proletarians We) a that he is attempt tnerebom and the base ba
a connection with row! adholvad by pitr�;Q bait N, 4 0.
a dismantling Irnpeot, will b more than Ih beei h ICM
Cts
with Applicant to a reit
the surged atem0lron Arty violation Of Seclron MIS by any applicant la A permit sublet"' Rye
demolition
CA.LJ
pensny of nor rr2re Ina, Ilve Amard dollars (LW.I:
will do the walk, and Ret
Inslrial
As ownn •builder, 1 ata rot empby anyone to d0 ova► rhiarwM rtpu■e a pelmet bpm Int Dlrnyon d6u
has a pwmfl to 60 Such wort trap mat division,
a/ rr.rW DI Rat popwty, a my employees with wages ale then sole compensation.
holesatons Coot Tyr Eemla[ta"a IKrn1t la.� �
atrry. u roled above. unless such person
b uaae m rot mtr1. nded a oUaed lot are (Sec 7W. Busyness and
and rho Goes sud-i vpL himsell a Imoupfi
p,'s'rw of MAis1�1a1 S.Teir�slmn No.
fT -. -
doff rot apply Io an o -neat at popetly who builds or improve tweon.
that such impovrmmis Not not Intended OF otle.ed lasatq R.No-•CRr the Dmhmp or
_vim y,.
tit �_ .- ADplicati
his o.n enlproyrn. P'o•ded
rmporrmmt a sad within One yaw Of eOmPlel.ort the o.nel.luildn will have try burden I wow tip 1Nn-he_dd m1 _
y %
ICANSIRUC110N LENDING A(�HCy: I IKytby ail•m that her is a construction land" agency for the pemurmance d
i • nice trusyceM a saued (Sec. 3W. cit. CJ.
build a rnpnwe to, Inc purpose d salaJ. ,
1T+r cool to,
1 as one, of tit pony. am eadusively conolratlmp with licensed a 011111 tole to woua[i the pro)a[1 (Sec. TDII
P!„xaa coot Tose Conuacta's license Law does notapply to an orae a property wlobuilds or--
j r`n{anoe t-mam1
I • , -,
all hotrsamrm
Imp ores err. bon and who contracts, to such po)eets with a r:orllranalsl lyCwaed. pursuant to that Conlnclopi �` lerow's"hildiess
/ vIl�inat'I Mate Ieab 1ti6 aDNy: anon and ire roar the above infamalron is wtew. I spree m oomph •la afl
I Ke'rat lawJ �_ - ._ __-
,A S. P.0 (Attach Certily[J1C)
"=
0 I r 1 beOf
Uly aha county orOmancn aro al]It laws Iola mp ID building construction. all Dy Umollit eD sm a r
to colo upon 1M aDO+e-menhOtytd property mlPeLTgn a ose
1 am twnor unOe SK _ - -
IM! county
.. ' :: .. .- . .. •.
•Date
Date __ D.ner _ _ __
.
SrynaWw of Applicant Or Apem
I n 'I that I r.a+t a [erbhcale.ol consem to "I!-msule. a a
O tui I I n tie stale teal Inc
wD''o,:IRS COUIINSAIIDN DECLARATION ellDy a•.Ins
certnh: zit of sum+ns' Cmmpcnsatbn Inlmznce. 01 a ceneym COPY tar�eol ISr. 3600, Lab C.)
Polbcy No Company ^
D Cend.ro COPY Is IxleDy Iurmstle0 ( ,
Cit r0 lei I cd em•1 Ounly 6unl01np I K:Irpr, 1 a C 'til Gt partmtnl.
0,Y%7_E� Apphtan71
(F
AP .CANT AA E F. MI)
Y7
ADDRESS
J �O ��
Cert."OV -UNIT T/SYATE(06`1 44 ZIP
JOB///"""SSMITE AD RESS.'SPACE
CIT y"Or."/UNII Y/STATEIZIP
BOK
PAG
PRC
C
Twee
RNG
SE
S
TRACT
r1l i ni
lOT
TOTAL
FEE
MOD
SB
TRACT NAME
OWNER NaME (L. F. MI)
CON7FiAC`F0R.FIR%A NAME
ADDPESS
CIT,,:C[+•'� 7••ITY STATE%ZIP
PHONE • LICNC
ARC:En1v FIRM NAME
ADDRESS
CrTY:CD%< ur:IIY:Sl AlEZIP
PHONE • UCNC ol
USE OF Fi."AIIT
Bl
AD
B
SSB
SSB
RSB I
OFC
--F
ZCNE
LOT SZ
ENO
51D'c
CERIIFICAIE 01 COMPLIANCE AND AUIHORIZAIION OF [WIRY. I cerinty I have Ica n app its Io a
mlolrrabon pi+en n [atecl I apiee to comply ff all Slate l� s an yUmy oidlnances rrtalmp to bued,rnp can
suuu and aulnprue a neDlesentahve 01 Ihr4�,� rl AG �•�f/ g.,ni of 6y'le�pp and Sal ty pan
I o t1 la .'lith 1 have applleb 101 this Pum 101 IM p nposi lel on n m" c
.am I p I o p t a
P A03I¢an1/AOenl Name
APPVPRMY PS DATE
D�
00 N o
X1741"52e /G'• Ca
s I 1<21
r1l i ni
TOTAL
FEE
�/ D_J