0207-054 (BLDG)LICENSED CONTRACTOR DECLARATION -- -- - —'---- -- u
PERMIT #
hereby affirm under penaltyof;rid jury that I arri licensed'.under provisions of
BUILDING PERMIT
H Chapter 9 (commencing with Section ;7000) of Division 3 of the Business and DATE. vA�unTION DoT•
N :� Professionals Code, and my License 1s in full force and effect
TRACT., S 5:
Llc. Class > Exp Dete APN
p c� License # OB IT
.3/31 /03 BLDf3 6
JOB . ' .
P+- W t� CONTRACTOR /DESIGNER / EN INEER r=
OWNER
Z DatSignature of Contractor
W:
-
O.„ ."'aRESII)EATLTAlA$9N....
.'� �
,. DII.. ASR FA/'�IC f3�ENER.P.I.. COAdTRAICTO
F= c OWNER -BUILDER DECLARATION 2s33 SOUTH COAST AiGHWAY gTE. 250
.: P O: 0 DX 1060. .
W W I hereby affirm.under penalty oYperl'ury.that I am.exerriptfrom the:Contractor's GA 92233 CA1tDIFFBYTHE SEE►. CA 92007
Ucense l:ew for the following reason -
,`QUIIdrA .
�7�ojsr gsoo..... _:. _ _ ' ...: _cBr 5823 ,�,
Z C..) , 'I, as owner of the.grope-ity.or_my` Amployees.with:wages as their sole ,
corripensation; .will do the work; and.the structure is not`intended or offered for
sale (Sec 7044, Business & Professionals Code). sof PERMIT
USE
(�) I, as.owner of the property dr exclusively contracting with licensed Q p,1;.gjjII,pgl(}
contractors to construct theprolect {Sec .7044 Business & Professionals
"' ,�.✓' �" `- SLD 6 i5?_392,-i5-b04,i�6t6, VO1:iJNT1AI'.Y-STRUCTUR�iL
. •-, . _. Code): �-*.�- �-k --
�'_ O`
-Tam exempt underSection =t B&PC. for this reason -
:...Signature of Owner
MCij7I1<iCATiONS
•CV:
WORKER'S COMPENSATION 6tdL-ARATION x '
,. Z
_�• I `hereb a'affirm under:penalty;of peryury one _of the ;following .declarations: -VALUATION �15�000-00.;L3.
o., �. Y
; I have and will maintain a•certicate of consent to self insure+for workers
1 . �,
I W_
LL compensation; as`provided for'by Section 3700 of the:;Labor Code for,;the
1 ' p X •..:� J v , work for
Which*
rfrlit �s.issued b�
O. perfomtance of the. Pe o L�
ntain iaorke�si coin " _nsaUon insurance as required try
<_0
(r ). I have; and ynll mai ;_•.._ -
U ` 3700=of the`trCode, for the performance of the work':for whicti`this ~�Y
Section _ r ;rte
�,� ',c - r rkefS' Corn nsatlon,rnsuranCe of &,p01iCy no, are:
r:, _ + •s
a rrrlit IS issued My;.wo Pe
cam -
I.Pe :..�: T, .� = - �. "' OST -OF CONSTRUCTION
3,000
I �.:�°'�. ;'„• Policy,No. r-;04601UNIT0009415 ,•;s $STIlVIATEDC.� . � � 1
-
,,.yv<_ •Gamer �STATEFUNp � � -Y
` PER1ViTT FEE SUI2ARARY '} �e
..� p�q hJ.
i not tie coin leted rf, the. permit valuation is for $10000 or less). COAISTRUCTION FEE 101 000-41 .
(Thls section need _ P ;
,( .)' I Certify, that in'ttie performance ofthe work'for which this permit is issued, STROPIti MOTIOPI FEE - RESID t01 -Q00-241-000
Shall not employ any person .n any:manner so as to become subject to`tFie L +
workers compensation laws. of. Califomia and agree that rf I should become
t; subject to the workers' compensation provisions of Section 3700 of the Labor.
s Code, I shall.forthwith comply `with thgse provisions
3
i Date: Applicant
Vit;
, xa�
z,. Wamin Failure osecure Workers `Compen"sation coverage Is unlawful and
,.
-
shall subject'an employer to criminal penalties and civil fines up to'$100,000, in
�5s 1
I ,..
addition to.the cost of compensation, damages as provided for in:Section:370fi
k arc
the'l:abor Gode 'interest and.attomey's fees;
IMPORTANT Application is hereby made to the ;Director a Bulldin and Safe
9 , Safety .
r�
^" for; a permit' subject to the conditions and
- restrictionet.`forth on his
�y
application t
1.::Each. person upon whose;behalf this application is. made &each person at SCJ$ TOTAL CbAT�PRIICTTOId AND PLAN CHECK $163 30'` ;
;whose request and;for whose benefit work is performed under or pursuant to / LESS= PRE -PAID FEES
any permit issued as a result of this`applicaton agrees to & shill, indemnify''.'
&=hold harmless the City of.La Gluinta its officers, agents and employees. }
f TOTAL PERMIT PEES DUE Now S163R'S0
+ 2 Any permit issued as a resuR of this application tipeomes _null and void if
n 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.
3 I certify, that I have read this application and state that the above Information is
yl •' 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: RECEIPT DATE BY DATE FINALED INSPECTOR
Date •
_;I Signature (Owner/Agent)
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that 1- Am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04Professionals Code,'and my License is in full force and effect.
LU
U cense # 'Uc. Class Exp. Date
co
733152 B 3/31/03
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I here . by affirm un . der pena . Ity,of perjury that I am exempt from the Contractor's
License Law for the following reason:
O 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),
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
am exempt under section .B&P.C.. for this reason.
Date Signat_ure.,of_Qwper_
WORKER'S COMPENSATION DECLARATION
I 'he . reby affirm rm Under .. penalty
ty . of perjury .one of - the following declarations:
O 1, have and will maintain a certificate of consent.to self -insure for workers'
* -
compensation, as.provided ,for by Section. 3700 -ofthe -Labor 'code, for the
perform . ance 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, fo, r - the performance of the work for which this
_permit .iS_:iss,ued..M workers' compe _nsabon �insurance carrier & policy,no. are:
Can* STATE FUND Policy N67 611601WIT0009415
(rhis section need not be completed if the permit valuation is for $100.00 or less).
I certify t I hat.ih 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 pensation laws of California, and agree that it I should become
subject to the workers' compensation provisions of Section 3100. of the Labor
Code, I Shall forthwith comply with thoseprovisio ns..
.Date: Applica
Warnirg Failure to secure' Workers' Compensation -coverage is unlawful and
.s . hall 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 .IMPOApplication is hereby made to the DireCto"riotpuilding and Safety
for . a permit subject to the conditions and restrictions 'S4, 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
any
& 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 160 days from date of issuance 61 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
DATE
JOB SITE
WILDING PERMIT OM7-W4
VALUATION 515,000.E 'LOT TRACT
BLDG. 6 P111:11!4:111:2�T "'
OWNER
PQA-WMRE=04T1ALASSN.
P.O. BOX 1060.
LA QLTWTA CA. 92253
USE OF PERMIT
GMMALB=1NG
ONTRACTOR/ DESIGNER/ EN INEER
DEL DEAR PAMC GENIMAL COIMAICM
-2533'90UTH COAST 0GHWAY2M 250-: -,1
CARDIFF ,BYTAE SEA CA 92007
BLDO. 6:-55.59;;,54_604j 55-616;VP LUNTARY STRUCTURALAL
MODIFICATIONS
VALUATION
CBLfi 5823
-ESMUTED COST OF CONSMUCIION
PERMrr FEE SUMMARY
C I ONSTRUCTION I FEE' 11'01w=-418-000 516 00
STROM MOTION FEE. RFsm 1014000-241-000
DATE
DATE
INSPECTOR