9609-130 (RC)LICENSED CONTRACTOR DECLARATION
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 # Lic. Class Exp. Date
�ll4 l"'L,i 8-1 C-20 C;-3 9/301!)-1
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that 1 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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section , B&P.C. for this reason
Date Signature of Owner
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*rP4ViA k4�s"compensation insurance camee�&i�poliby no. are:
Carrier Policy No.
(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 those provisions.
Date: 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 Applicationis 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, indemnify
& hold harmless the City of La Quinta, 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-mentioned property for inspection purposes.
"Signature (Owner/Agent), Date
PERMIT # CONTROL #
BUILDING PERMIT'. 960,9 30 11
4
DATE 9117/96 VALUATION $9.7..50.00 . LOT TRACT
JOB SITE 78-41.1&. 7X.-417 !k %VY .1.11
APN
ADDRESS
OWNER
CONTRACTOR /DESIGNER ENGINEER
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LA.QCJ1wl,A (-:A 92253
f>AIJV1 0. 133 SI R`1° CA 9` 261.
(6,19)34.1 4510 C13.L # ' 3,526
USE OF PERMIT
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CISITi.MA T ED ICW T OF CONS'$°RrlUMN
9,750.0t;
PLAN C'.Hftt;`K:l;'I~i
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litEC:'.` RIC;.'A1:, RR.* I0I-iff:3(D-4200)0 V 5,00
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CrOMS'1;RUMON AND :PLAN IES':
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
i 4
BURNETT DEVELOPMENT COMPANY
September 14, 1984
:CEIVED
S k P 17 1984
CDMMUNTA
!PY pETV VEISPMENT DEPT
Please let me know if you need any further.information
in this regard.
Very truly yours,
F
William F. Burnett
WFB:jh
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500 East Cordova Street, Pasadena, California 91101 (818) 795-9556
Mr. Larry Stevens
Community Development Director
City of La Quinta
.P. 0. Box 1504
78-105 Calle Estado
La Quinta, California 92253
Dear Mr. Stevens:• .
I.have made arrangements with the Democratic -Party
Headquarters to rent space at Plaza La Quinta Shopping
Center on a temporary basis.
The purpose of this letter is to give you written
•�';��
authorization to provide electrical service for the
period from September 20 through November 8 and to
discontinue the service at the end of that time period.
Py
The address of the location they will occupy is:
78-417 Highway 111.
Please let me know if you need any further.information
in this regard.
Very truly yours,
F
William F. Burnett
WFB:jh
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pr k,4 -j P Aft OS G ELeC PPL' SOM/(CE oN (1AIS IN'
f PCT- �i•t15 LE17EI�- . S�N��L� Fouoy�/ Af E.JD oj- j�1Pbw�`y
500 East Cordova Street, Pasadena, California 91101 (818) 795-9556
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