TT (04-3543)55375 Medallist Dr
04-3543
P.O. Box 1504 • /: •
VOICE (760) 777-7012
78-495 CALLS TAMPICO FAX .(760) 777-7011
LA QUINTA, CALIFORNIA 92253 -- INSPECTIONS -(760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number. 011- 3,5- .v3 Date.' " Z
APPlicant: Cc n/ n c.7-cw
Applicant's Mailing Address:
Architect or Engineer.
.Architect or Engineer's Address:
Uc. No.:
BUILDING PERMIT DECLARATIONS .
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm under Penalty of perjury that I am;EHo__14
hapter 9 ( xneing with Section 7000) of Division 3 a the Business and Prolessionals
License e.and my Lice in lu1 force and effect O i
Date _Contractor
OWNER$1JUMER DECLARATION
1 Eby affirm ynder Peery of perjury that I am exempt from the Comact=V State License Law for the following reason (Sec. 7031.6. Rashness and Professions Code: Airy
City Or county that @q&"s permit b cosbuct, alter. improve, demolish, or repair any structure, prior to issuance. also issuaalso requires the applicant for lhe permit b fie a signed
statement that he or she is licensed pursuant b •he provisions of One ConOracbrs' State License law (Chapter 9 (commencing with Section 7000) of Division 3 of fie Business
and Professions Code) or eat he «she Is exempt ferefirim and Qu basis br the sloped exemption. Any violation of Section 7031.5 by any ;16 P Iforapermitsubjects
the e;; Ii"an- b o'civil penalty of not more than five hundred dollars ($5<%r
U I, as owner of the property. or my employees with wages as their sale compensaiat..will do the work, and the structure is not Intended or offered for sok (Sec. 7oa4.
Business and Professions Code: The Contractors' State License Low does not apply to an owner of properly who bwlds or improves thereon. and who does the wok
himself or herself or trough his or her own empboyees, provided that the inprovements are not intended or offered for sate. If, however. One buidmp or improvement is
sold within one year of completion, the owner4 Ader will have the burden of proving that he or she old not bold or improve br the purpose of safes
U 1.0s owner of .rhe property. am exclusively contracting with parsed contractors to construct the project (Sea 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner of property who builds or ImProves thereon, and who contracts for the projects with a contractor(s) is rased pursuant to
the Contractus' State license Law.).
V 1 am exempt under Sec. a.& P -C. for ants• reason
/ T
WORKERS' COMPENSATION DECLARATION
1 hereby affirm under penalty of pe*n one of the folowing declarations:
_ I have and willmaintain a certificate of consent b sell -Insure for workers' compensation, as provided for by Section 3700 of the labor Code. for the performance
of the work for whtid this permit is lssued.
_ 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
lswed. f+ty.wakens' Qmpensabw insurance carrier and poky number are:
Carrier /'ma c r Policy Number 7 1 y %
—I certify that, in the performance Of rhe forOwhhhIch this peril is issued. I shall not employ any person in any manlier to as to become subject tote workers'
Compensation laws of California, if I should become subject b rhe workers' compensation provisions of Seclim 3700 of the labor Code. I sinal
forthwith.comply with those
Date V Zf, -6
WARNING: FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFIX. AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CML FINES UP TO ONE HUNDRED THOLMAND DOLLARS ($100.000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN'
SECTION 3706 OF THE LABOR CODE. MEREST. AND ATTORNEYS FEES. .
CONSTRUCTION LF-NOWG AGENCY
I hereby affirm ander penalty Of
Of perjury rat there is a consbuckm lending agency for the performance of the work for which this
permit is issued (sec. 3097. Civ. c.)-
tenders Name
Lendees Address
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Appioation Is hereby made to the Director of Building and Safety fora Permit subject to the conditions and restrictions set forth on this application,
1. Each Person upon whose behalf this application is made, each person st.whose request and for whose benefit work is performed under or pursuant toany permit
issued as a result of this application, the owner. and the applicant, each agrees b. and shad, defend. indemnify and hold harmless time City of Le Oukrta. its
officers. agents and employees for any act or omissio&,elW
performed under or following Issuance of Ws permit
. 2. Any Permit issued as a result of this application becomot commenced within 1r0 days from date ofissuance of such pemhit, or
cessation of work for 180 days will subject per mit b c1 certify that I have read Ws appicaion and state that the above bconstruction, and hereby authorize representatives ol this oouMy >ay with an city and County ordinances and state laws relating to building
Property for Inspection purposes.
Date Signature (Applicant or Agent)'