04-3632 (RR)P.O. Bt)X 1504 a U��
VOICE (760) 777-7012
78-495 CALLS TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 40
INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number— �{ — x(03 a I Date*
Applicant:
Applicant's Mailing Address:
Archftect or Engineer.
Archftect or Engineer's Address:
Lic. No.:
BUILDING PERMIT DECLARATIONS
LICENSED CONTPACTOR•s DECLARATION
1 herm:by affirm under penalty a PMxy riot I am licensed under
:ond Provisions a Chapbr 9 (commencing with section 7000) a Division 3 a ft Business and Professionals
dg, nmol my I: in tones aeffect
/�
Date —2G ^GL
OWNE,R-BUILDER DECLARATION
I �Y � ^ Ply of Pe*xy that 1 am ezampt tram the Comtr*ctors• stab License Law for the faMawYq reason (Sec. 703.1.5. Business and Professions Code: Any
city or cm* that mq A= s pem*t b eornbuck alter, kwow. demolish, or repair any ctnuctunb. Florio Its issuance. also requires the applicant forte permitlo Bea signed
statement that he or she Is licensed Pursuant in the p Asions Of the Contracbm Stab License Law (CtwPbr 9 (commencing with section 7000) of Division 3 of the Business
and Professions Code) or that he or** to exempt tm ah6nm a od'the basis forte alleged exerrptia► Any violation of Section 7031.5 by any applicant for a permit subjects
the applicant b a CM penalty of not more than On hundred dollars 4500).):
U I. as owner. a the o s my empbyees with wages as their 6018 oompensation,.will do the wok, and the struWxe is not intended or offered for sale (Sec. 7044.
Business and Professroftnion Code: The C0n63dW Stab License Law does not apply to an owner of property who builds or impeoves therem and who does the work
hi mself or i mm or trough his or her own employees, provided that the improvements are not Intended or offered for sale. If. howeyer. the or
is
sold will*% one yaw a completion, the owner-binAder will have the burden a proving that he or she did not build or improve for the purpose a sale. improvement
U 1, as owner of the property. am exdu A,* contracting with licensed cw actors b construct the project (Sec. 7044. Business and Professions Code: The Contractors!
stab License Law does not apply to an owner at property who bunds or improves thereon, and who contracts for the Mviects with a contracbr(s) hotted pursuant b
the Contractors' Stab license Law.).
U 1 am exempt under sea . B.& P -C. for this reason
Dale.. � Owner
affirm under WARS' COMPENSATION DECLARATION
1 hereby a
penalty a perk" one a the following declarations.
_ I have and will maintain a certificate of consent b selfinsura for workers' compensation, as provided for by Section 3700 of the Labor Code. for the perbmmano;
of the work for which this per.. is issued.
1 have win maintain workers' compensation inrs,xanoe. as required by section 3700 a the Labor Code. for the performance of the work for whirl this perm* is
My w9dw4s. S 't'y*` m—• POictir carrier and policy number sre:
Number
ICOW 1hak in the Pwbmwm at the work for vrt:ctm this pem*t is issued. l shall not ernpby any person in any mariner so as to become
compensation lawns of Caifomia, and, agree that. If 1 should become subject b file workers' subject b the workers'
brhw(th comply wNi those provision. O0^mP t0f1 Pno+^olO^s a Section 6700 a the Labor Code.1 shad
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUB:IECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CML 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 ATTORNEY'S FEES. .
rm under CONSTRUCTION LENDING AGENCY
I hereby affim
penalty a Perjury that there is a construction lending agency for the performance of the work for which this permit is Issued (Sec. 3097. Civ. C.).
lenders Name
Lenders Address
APPLICANT ACKNOWLEDGEMENT
IMPORTANT
Application Is hereby made to the Director of Building and safety for a.pertdt subject to the conditions and restrictions set forth on this appicalim
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 b anymit
Issued as a result a this aPpication, the owner. and the appicaK each agrees ban
. d shall. defend, indemnity and hold harmless the City a La QukNa, s
officers. *Perls and employees for any ad or omission related b the work being performed under or k4owing issuance a this peril.
2 Any Penh issued as a result of this application becomes null and void K work is not commenced within 190 days from date of issuance of such peank or
certify
a work for 180 days YA subject Permit b cancellation.
I read this application and state that the above Information is eoffect. I agree to comply with an city and county ordinances and state laws relating b building
� and
t� hereby authorize representatives Of this county to enter upon the above-mentioned Property for inspection purposes.
Signature (Applicant or Agent):