04-3630 (RR)I
P.O. Box 1504 s����/
VOICE (760) 777.7012
78-495 CALLE TAMrlco FAX (760) 777 -7011
LA QUINTA, CALIFORNIA 92153 C&f 4 4INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number: 0 - 3 6 d Date:
Applicant:
Applicant's Mading Address:
A.
Architect or Engineer.
Architect or Engineer's Address:
Lic. No..
BUILDING PERMIT DECLARATIONS
LICENSED CONTRACTOR`S DECLARATION
I hereby atfrmm undo penalty of perjury that I am unset under provisions of Chapter 9 (connmenckV with Section 7000) of Division 3 of the Business and Protessionals
a si lome is iT�brc_a and .efect-boene�?o q�V
Dale LZ 6 - ct.+
EEf
OWNEA4WI .DER DECLARATION
l hereby off n. W dw penalty of perjurythat I am exempt from the Contractors• State License Law for the following reason (Sec. 70.3.1.5. Business and Professions Code: Any
dtY or oouny MM Mq*" a PWM b trorrsLuct a11er, improve, dernoish. or repair any wuox% priorso Is issuanm also requires the appficsnt br the permit lose a sgned
statemeN that he or she Is licensed pursuant tote provisions of the COntrOcime State License Law (Chapter 9 (eo wnemeing with Section 7000) of Division 3 of the Business
and Professions Code) or lhat he arsine is exempt Im -11611 and the basis for the alleged exemp6m Any violation of Section 7031.5 by any RPPI for a perms subjects
the applicant to a civil penalty of not more than live hundred dollars (5500�r
U 1. as owner of the property, or my employees with wages as their 6018 oompensaion,.wil do the work, and the structure is not intended or offered for sale (Sec 7014•
Business and Professions Coda The Contrauclols` State License Law does not appy Io an owner of properly who builds or improves thereon, and who does the work
himself or herself or through his or her own employees, provided that the improvements aro not intended or offered for sale. K. however, the building or improvement is
sold within one year of completion, the ow(brbialder will have the burden of proving that he or she did not build or Improve for the purpose of sale.).
U 1. as owner of the property, am exclusively contracting with licensed contractors to CO WJW the project (Sec. 7044. Business and Professions Code: The Contractors'
state License Law does not appy b an owns of property who builds or WW*ves thereon, and who contracts for the projects with a coatractor(s) incensed pursuant to
the Contractors' State License Law.).
U 1 am exempt under Sec. . SA P -C. for tris reason
Dale" Owmmer
WORKERS'COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations.
_ 1 have and will maintain a eetiErate of consent to setl4nsure for workers' compensation, as provided for by Section 3700 of the labor Code, for the performance
0f the work for which this permit is issued.
1 have and will mairdainrs
co peation as required by Section 3700 a a the Labor Code. for the performance the work for which this permit is
' m px t, Nwnber and poky nunmbet are:
._ I certify It%* in the performance of the work for which this permit Is Issued. l shad not employ any person In any manrmer so as to become wbf d b the workers'
compensation lows of California. and agree VOL I 1 should become subject to the workers' compensation provisions of Section 3700 of the labor Code. I shall
iorOnNth_eonply with those pmvWonL
Z6 "U
WARNING: FAILURE TO SECURE WORKERS COMPENSATION COVERAGE Is UNLAWFUL. AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100.000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST. AND ATTORNEYS FEES. .
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that two is a con struction landing agency for the performance of the work for which this permit is Issued (Sec. 3097. Civ. C.).
Lenders Name
Lenders Address
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Appicatim is hereby made to the Director of Building and Safety for a hermit subject to the cor4lions and restrictions set forth on this appicaGon.
1. Each person upon whose behalf this appicatim 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 application, the owner. and the applicant ca each agrees b, and shalt. defend. indemnify arrf fold harmless the City of L e Quints. les
offioes, *gents and employees for any ad or omission related to the work being performed under or following Issuance of this permit.
2 Any pemmit issued as a result of this application becomes null and void I work is not commenced within 180 drlys from date of issuance of such pemmit, or
cessation of work for 160 days will subject pemdt to cancellation.
1 certify that I have read this application and state that the above Information is COffOCL I agree to comply with ad city and county ordinances and state laws relating lo building
construction. and hereby auluxim representatives of this county to enter upon the above- mentioned property for inspection purposes.
Signature (Apptia" or Agent):