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LICENSED CONTRACTOR DECLARATION*
I hereby affirm under penalty of perl'ury*that I am licensed under provisions of
Chapter 9 (commencing with Section MOO) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Dat
Date Signature of'CoMr—t
OWNER -BUILDER D RATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors
License Law for the following reason:
( ) 1, 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).
( ) 1, 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 worke rs'
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 foe which this
permit is issued. My workers' compensation insurance carrier & policy hd.'are:
Carrier Policy No.
DRA114 u4s. CO', MV2066VOT
(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,-aCnd agree that-if-1`60ould become
su6ject to thd woykers' compensatio n_____
provisions�of;Sectiori�-3700 of the-Lador
lZode, 11. s, all fort it comply with those-proV
'0, -
'/Date: - 1 7' _�Applicant-----�' c�'_
Warning: Failure to secure Workers' Ce pensation coverage is unlawful and
shall subject an employer to crimina penalties and civil fines up to $100,000, in
addition to the cost of compensati;n, 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 madeA each Oerson'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
correcItell agree to comply with all City, and State laws relating to the building
con t�uction, and hereby authorize representdtives of this City t0.eht6r upoh
2 6 above-mentioned property for inspecticr�urposes�-
gnature (Owner/A Date
PERMIT# CONTROL#
BUILDING PERMIT
4953
DATE 4/ 7t97 VALUATION. 25301.1
LOT. TRACT
JQB,SITE APN
-ADDRESS 45-160 1ARIDGM-31E WAV I
OWNER
"J
'E"'FOUIlY C41RU.J:V11 EU CO3,A,11N,1UtJWNE8
035 S -40i K1,
SAN BERNARDIN0
CA 97-4108
USE OF PERMIT
/DESIGNER/ ENGINEER
ri _r
153 i so.- "Vill
SAN BERNIAKAM.) CA 9240"S
(%�psj -&)0,7 . C.RL! 2120
00,REY. (-*I,,4kN -AKH, PLAN C."hECK 1"Er"31
FOR
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J)E Qf 1AW �41 Vr-
1,441.00SW
36.00 SF
C,'ARAQ1WARIXQKr 4 124.00 RF
COST or, CY)NISTRUCTION
i*AW
r. ONS1 R1IJr_*r f ON FE 17
SIB-,
MW1114MACAL FEE,
10 t .00OA21 -000
V*1Lb_C1rP11(11AI�-AbZ:
I .40:kM-420-000
PLUNWINO FOR
$118
-vow-cl mcyy f0N twtml)
'101-00KII-2 41-01%
ORAMNa IWE
101-000-423-000
$20
11,011RAITFRMT11*9 FF9
')L�-000-443-142
S1,967
,72
'50
M
. 90
.00
.79
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Aj
PAIUvwAL COWORUCTION . ANDP1,.A_NC1fl!(_`k-
LESS PRE-PAIDPETS
APR .0 81997
M
rMCAL-PERNITFF, S01,00NAr
iTY C)F,LA QUNTA..-.
RECEIPT
INSPECTOR
4
$0,00
$2,976,0Z