9911-010 (AR)LICENSED CONTRACTOR DECLARATION.
(hereby affirm under penalty of perjury that I am licensed under provisions of
hapter 9 (commencing with Section •7000) of Division 3 of the Business and
NW Professionals Code, and my License is in full force and effect.
Licensee Lic. Class Exp. Date
o v a74111 P A t 1/31/1
on r --ate' Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
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'.
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. My workers' compensation insurance carrier '& policy no. are:
Caner Policy No'.
7ATEM-9� tlz3`IT 49IJ
(This section need not be completed if the permit valuation is for $100.00 or less).
R`, O 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 :1aws of California, and agree. that if I' should become
sub' to. the workers' compensation provisions of Section 3700 of the Labor
CAB, I shall forthwith comply with those provisions.
ate: Applicant
Warning: Failure to secure Workers' "Compensation coverage is unlawful and
shall subject an employer to crimirial'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 Application is hereby made, lu ll e Diredor of Duilding, and Safoty
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.
I 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.tp the building
cons
the property fori
tr • ction, and hereby authorize representatives'of this City to enter upon
ove-mentioned nspection purposes:.
ignature (Owner/Agent) Date
PERMIT p
BUILDING PERMITa>z�
DATE i VALUATION "7.00LOT TRACT
JOB SITE
ADDRESS ,5Y-275 Ct�.L LE QUITO
APN 76.9A42-014
OWNER
CONTRACTOR / DESIGNER / ENGINEER
GEOP.051A CLARKE
t. SMG CONSULM.1 SERVICES
51-275 C;.ALLE.QW0
51275 CALLS QLM
LA iWNTA CA W2233
LA 44��MfA CA 92253
(:7 3 7}'1-3311d C2"
USE OF PERMIT
•}C1, SIDEYf' lAL A -FA) i` ON
' . .
WPt ,E 04 t AL O PERNT 29444- 0 , S.F.- LN INN "A,
Tr) NUAf+_X i id..c !()M A€ DITIUN W MLE UNUFAk CJN$$'1tr G I` u (AHM
C CA]OPMINAPION E"HANOBS 0,1'n At,t)'a
Ai.3sMKIT4 3Q.og V
t
I<;.'R'3'tMa 'I`ED CWT (W CIMSTRUMON
4oU7.09
PXRMIT FEE SUMMMY
PLAN CHECK EEE-* 101-000-439318'*$4640
!0140)419 -Io►
1014) M -420-€ W 33.15
STRONG MCITION, U =RESID
ART INVUBLIC MACES - R&M 701> X45 -41F4 Sti1 :
F
P..fWMWAL COME RUMON AND PLAN CHECK
$134.67
LESS PRE -PATI-% F ES
$10.04
RECEIPT
DATE
eY
DATE FINALED
INSPECTOR
�r BOB HOFFMAN , Structural Engineer ? ;
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xAtfaro Drive, . Ranc gage 9227 CV
Tel /Fax. (7 ).568-2967
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BOB HOFFMAN , Structural Engineer
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