04-3583 (RR)P.O. BOX 1504 UW(VOICE (760) 777-7012
78-495 CALLS TAM►ICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 440
INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number. Jr$� Date:
Applicant:
Architect or Engineer.
Architect or Engineer's Address:
Lic. No.
ISUnLL)ING PERMIT DECLARATIONS
1 hereby affirm under LICENSED CONTRACTOR'S DECLARATION
PAY or PMerY that I am licensee under povisians of ChaPbr 9 (commencing with Section 7000) of Division 3 or the Business and Proltmoonels
a 61oerCae is lip prljoroe and effect
s `"( No -7-7 a
1 hereby alum under penalty of Perjury that I am
OWNER -BUILDER DER DECLAftAT10N
city or county that requires a permit b construct, � from pr . Contractors• Stab License Law for the following reason (Sec. 7031.5. Business and Probssions Cods: Any
staleeront that he or she is licensed �• d°010� or MW any d m ctuM D� b Its issuance, also requires the applicant for the Parma b tie a signed
and Professions Code) or riot he or she Iexempt ltptAft or Rro Contracbrs' State License Law (Chapbr 9 (eonxnencing with Section 7000) of Division 3 a the Business
the applicant b a slit ri°rohorn and the basis ler the aleged exemption. Any violation of Section 7031.5 by a^Y applicant ler a permit subjxts
pdmalty of not more than five hundred dolars (SSW).):
U I. as owner of the property. or my employees with wages as their sob compensation, will do the work, and the structure Is not Intended or offered for sale (Sec. 7044,
Business and Professions Code: The Comtracbrs• Stab License Law does not appy b an owner of property who builds or improves thereon, and who does the work
himself or herself or through his or her own employees, provided that the Improvements are not Intended or offered for sob. It. however, the build rg or improvement is
sold will*' one year of completion. the owner -bolder wit have the burden of proving that he or she did not build or improve for the purpose of sale.)_
U I. as owner of the Property. am exclusively contracting with licensed oonlracim 10 eruct the Project (Sec. 7044, Business and Professions Code: The Camwactors'
State License Law does not apply ban owner of property who builds or improves rieieon, and who contracts for the projects with a contracbr(s) icensed pursuant b
the ContracbrV State License Law.).
U I am exempt under Sec. . 8.3 P.C. for this reason
Date Owner
1 hereby affirm under penalty of perjury one of the following declarations:
WORKERS' COMPENSATION DECLARATION
—I have and wit maintain a certificate of consent to sell -Insure for workers'
of the work for which tins pen. Isksued oDrmpensation, as provided for by Becton 3700 of the Labor Code. ler the performance
I have nd will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code. for the performance of the work br which this perit k
S is compensation eamiar and policy number aro:
_ 1 ce" #A In the Perlomnanee of thew k br wlmiclm rile pemtit k Issued. l anal mol
comperxa6orm laws of Caifornla, and Spree Not. if 1 should become e(Wker any person in any manner f e io become3700st o La b the workers'
t ftft.�y with those Grovidons subject b the workers' compensation provisions of Sesdyor► 3700 of the labor Code. l shat
n t,
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE ISflIL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE Fllffr0RE0 ThgUSAND DOLLARS ($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. .
I hereby affirm under CONSTRUCTION LENDING AGENCY
penalty of Peju!y that there k a construction lending agency ler the Performance of the work ler which the permit is issued (Sec. 3097. Civ. C.).
Lenders Name
Lenders Address _ -A
IMPORTANT Application is hereby made 10 the Direcbr ofAPPUCANT ACKNOWLEDGEMENT
I. Each person upon wase behalf this Building and Safety ler a permit subject b the conditions and restrictions set forth on tis application.
Issued es o rosin of this a application Is made, each person at whose request and for whose benefit wok k Performed under or pursuant b any permit
officers, ppication, the owner. and the appicant, each agrees br. and shall, defend. indemnify and hold haless the City of La Ouk ta. its
agents and employees for any act or omission rel
2 Any Permit issued as a result of this application becomesated to the work being performed under or following Issuance of Ws permit.null and void if work is not eommmenoW within 160 days from date of issuance of such perms or
cessation of work ler 180 days wN subject Permit to cancellation.
1 certify that I have read this appicabon and state that the above Information Is correct 1 agree to comply with all city and county ordinances and state laws relating to
construction. and hereby authorize nePreseWzbves of this county to enter upon the above-mentioned property ler inspection purposes. building
a e —2L
gnature (Applicant or Agent):