9904-196 (AR)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjuiy, that'1 am licensed under provisions of
:-4iBpter.9 (Commencing with 'S.ection'7000) of Division'3 of the Business and
Pi6fessionals Code, and my License is in fUll.f6r( eand effect.
..:License#
Lic. blass Date
7
72�11 7
7��
- - Signature of Contractor
OWNER -BUILDER DECLAR N
I, hereby affirm under penalty. of perjury that 1. exempt from the Cdntractoes
License Law iorihefollowing reason:
1, as ownd.i'o . f . the property, . . oir—m'y 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 OW
. ner.-of. the property, am, exclusively contracting 'with licensed
Contractors to construct the project (Sec. 7044, Business & Professionals
Code)...::.
b 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:
-1 have:and..wili maintain &certificate of consent to self -insure for workers'
compensation, 4s. provided for by Section 3700of the Labor Code, for the
Pplor.mance.of -the Work for which this permit is issued.
ff I have ano.will maintain workers' compensation insurance, as required by
V
'on performance . 3�00 Of the Labor Code, for the performanof the work for which this
pe . rmit is issued: "My workers' compensation insurance carrier A policy no. are:
Cahier. 'Policy No.
S TAT E PJND 1"11943 Ma 00IM5
section need not be completed. If the. permit valuation is for $100.00 or less).
I certify that in theperformance of the.work for which this permit is issued,
[..phall not employ any person in' any manneLso as to become subject to the
w
_�gorkers' compensation laws of Califorgoi;a ree that if I should become
sybJect to the vifters' compensatioYr5rWisionsh)f Section 3700 of the Labor
Applicant
Warning: Failure to secure Workers' Com ensa, ion rage is unlawful and
Shall subject an employer tqlcn*minal ties and civil fines up to $100,000, in
a
addition to:the cost of comp # 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 subiect 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
an.Y,permit issued as a result of this.applicaton agrees to, & shall, indemnify
&.:hold wharmless.the City of. La Quinta, its officers, agents and employees.
.2. Anypermit issued as a respl . t.of this application becomes null and*void-if
`-_wbrk.is not commenced' . within 1.80 days from date of issuance of.s'uch
`'-permft,.or cessation of Work for 18.0 days will subject permit to cancellation.
.1. certify that I have read this application and state th4t the above information is
Correct. I agree to comply with al d State laws.,relating to the building
rep construction, argd-hereby-aft ize re tatives of this City to enter upon
" - I
the above -mention I c to urposes.
g
Signature (Owner/Agent
Date
PERMIT#
BUILDING PERMIT
9"4.196
DATE VALUATION LOT TRACT
JOB SE
ADDRESS :M-475C.ALLE QUffO
APN
769-14MI4
OWNER
CONTRACTOR DESIGNER EER
OEORGINA Q. Llklm�
I-SMIG CONSWMIG SERVICES
51-275 CALLE QUTM
5075.cAw.. Qum
LA WNTA CA #2253
LA.QUMfA CA. 92253 -
(76 )77i 1-M CBL# 4980
USE OF PERMIT
kES;1DEN1'W,ADDM(NN
ON, 413 8-F..:GARACiF3 AWITION
AWDIMON F31F
GARAGOCARPORN 433.1* 3F
1=11t'iATED CM OF CONSTRIUCTION
2
PERMIR FM SUMNtARV
PLKN CWX FFE 101:-IlUfi-43y-::11LS X53'+.10
KI " 10 N W, F
NTICILVOML M 10 1 0 42) $47.00
ELEC�MCAL TIFF 101-000-42-0" $120.86
-P'LUWtW FEE 101-000419-000
M, 0NQ MOTION FEF RESID 1.03 -1N} $10.73
GRADING M S 2 0. (K)
PRWW,PLAN .101-000441-345 $21%.00
.AKU I'N PUHLK"PLAC%3 - RESWIOI-OW-25,5-(W 518,28
SU84MAL CON87RUCTION ANT) P! �AN (1ECA
$1,S27.47
LESS PRE -PAID FEES
50.00
TMAL PEMIT FEES DUE NOW
$1,527.47
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR