04-3625 (RR)1
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P.O. Box 1504 e ��G�w,
VOICE (760) 777-7012
78-495 CALLS TAM►iCo FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number. _ B q;10Q "57 I Date:
Applicant:
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Architect or Engineer.
Architect or Engineer's Address:
Lic
No.,
. . . �L) 16- .
BUILDING PERMIT DECLARATIONS
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under Panapy of pedury that I am licensed oder provisions of chapter 9 (oomman*V wdh Section 7000) of Division 3 of the Business and Prolessionals
Code. and my License Is in kA save and effect.
OWNEA4DU1lDER DECLARATION
I hereby arm., ynder peter of Perjury that I am emrpt from the Contractors! Stab License Lor for the klowkV reason (Sec. 7031.6. Business and Professions Code: Any
City or Courmty that Lemmas a pen * b construct• after. Improve, demolish, or repair any Stucture. prior b Its issuance, also requires the mftw t for the permit In fib a signed
r talement that he or she k licenced Pursuant to the Provisions of the Contractors' State Uoen$a Law Poplar 9 (commencing with Section 7000) of Division 3 of the Business
and Professions Code) or that he orshe k exempt theretrm m and'the Mask for the alleged exemption. Any violation of Section 7031.5 by any ton a Permit subjects
the applicant to a dvi Penally of not more than On hundred dollars (s6Wo y
U I. is owner of Mme property, or nny"empbyees wdh res as their sob compensatim will do the }Mak and the Structure Is not Marded or offered for sale (Sec. 7044,
Business and Professions Code: The Contractors' Stale License Law does not apply to an owner of property who builds or improves thereon, and who does the work
himself or herself or through his or heroim «mpbyees, provided totthe improvements we not Mended or offered for sale. I, however, to building or improvement is
e
sold within eryear of compk % the currier bidder will have the burden of proving that he or she did not build or improve kr the purpose ".)-
U U L ss owner of .the property, em exckesively contracting with licensed contractors to Construct the pm)W (Sec. 7044, Business and Proiessbm CWe: The Contraclors•
Stab License law does not apply to an owner of property who beads or improves thereon, ad who contracts for the projects with a contn..ctor(s) licensed pursuant to
the Contractors' State License law.).
U I am exempt under Sec . B -b P.C. for this reason
Dale'. Owner
1 hereby affirm under Wim' COMPENSATION DECLARATION
penalty of perjury one of that following declarations:
_ I have and will maintain a certiGgk of consent 10 seliinsue fa workers' compensation, as provided for by section 3700 of the Labor Code. for the perfomonoe
of the work for which this per.. at Is bsue&
I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code. for the
Issued. My workers' comDa►satian l� carrier and policy number aro: Die a the work br which this permit k
�C`artler STV►-t�C r -v SCJ Nor
_ I Certify that, in the P&Umaixe of the work for which this permit Is issued. I shag not employ any person in any manner to as b become subject to the workers'
Compensation laws of Ca"omia, and agree that, If I Shoda become subject to the workers' compensation provisions of section 3700 of the Labor Code. I shall
1bfVw th.oam,py with those provisions.
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WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CML FINES UP TO ONE HUNDRED THOL MIO DOLLARS (=100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, MEREST, AND ATTORNEYS FEES. .
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there Is a construction WxkV agency for the Performance of the work for which this permit is issued (Sea 3097. Civ. C.).
lenders Name
Lenders Address
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Apptiptiort Is hereby made to the Director of Butidirg and safety for a permit Subject to the conditions and restrictions Set forth on this 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
Issas a result of this application, the owner. and the applicant, each agrees to. and shad. defend, indemnify and hold harmless the City of La Ouiota, its
agents and employees for any act or omission related b performed the work being perfoed under or fodo,,ing issuance of this permit
2- Any Pena 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.
1 eerwy that I have road Ws application end state that the above Information Is cared, 1 agree to comply with ad city and County ordinances and state laws relating to buildingconstruction, and hereby authorize represeWativero
s of this county to enter an the above-mentioned property for inspection purposes.
p�e�t 'LCC - U�� here
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