0201-068 (BLDG)I hereby affirm under penalty of perjury that I am licensed under provisions of
Cl)
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04. WProfessionals Code, and my License Is In full force and effect.
G 5 C) License # Lic. Class Exp. Date
r-. Cy In
UJti 73:3152 13
03113 r.1/2(
6 z Date Signature of Contractor 1
;e
OWNER -BUILDER DECLARATION
_J
LLI L) W~ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z ( ) 1, 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).
I,- as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business Professionals
Code).
ce) I am exempt under Section B&P.C. for this reason
0
04 t Date Signature 'of 'Owner
�-o C\J
WORKER'S COMPENSATION DECLARATION
�l hereby affirm under penalty 'of perjury one of 'the following declarations:
a:
U) <
F.; 0 O -1 have and will -maintain A.c6rtificAte of consent to self-insuee for workers'
XALI :c,ompensatlbn; 'as provided for by Section 3700, of the Labor Code, for the
0
.J performance of the work for which this permit is issued.
co < (d have and will .maintain Workers' compensation insurance, as required by
Ci 9 Siktlon 3700 of the Labor Code; for the pe-iformance of the Work for which this .
a LQ permit is--Issued.,My Workers' 'cbmpensation'insuirance carrier - & policy no. are:
z Carrier
Policy No.,
ob STATE FUND
0.
(This, section need not be completed if the, permit valuation is for $100.00 or.,Ies�s).
i In1hia performance of the work'for which this p r ermit is is'sued',
I . 'Icertify that shall rioi• employ'*any person 1n any manner so as to becomesubject to the
a
work6es' 60mpensmlon'laws'of California 'and agree that if I should
hould become`
subject 6 the workers' compensation -provisions of Section 3700.Of the Labor
Co'de,,11" shill fort with comply with those proy/ris SIO
.,Date: AOplicant'
�4,^,Wathlh§'-:FailUr(i-to',secure Workbrs"Compensation coverage is unlawful and'
'J-ZshaIFsubject an 6 criminal
mpI6 to cr penalties and.civil fines up to 600,000,.in
�,-�dddiii8h10 the cost -of compensation, damages as provided for in Section 3766.
-hof theIabor Code, Int4iest and attorneys fees.
SP
2 sir;'�",AIMIPORTANTApplication is hereby made to'the Director of Building and Safety
dy�� 4forga�permd subject to the co _J: d
M
h ni itions an restrictions set forth on his
'application
; -
rtr "d , Each perion-upbri whose* behalf this application is madel.each person at
Whose request and for
whose benefit work is performed under or pursuant to
issued fy permi is u.e . s a :result of this applicaton agrees to, & shall, indemnity
holdharm I less the City of La . - Quinta,- its officers, agents
ents and efiiployees.
?Any ermli,SUBd as a result of this. 'ippl: ati'
a ic on becomes null and void if
,'work is not commenced within 180 days from date of issuance of such
< ermif, or -cessation of work for 180 days will subject permit to cancellation.
I that
I haviii"read this applicati . on and state that the above information is
g rr t. I agree to: comply with City, 6' a 11` 6t
y, and State laws relating to the building
c ristruction, and here y-aut onze representatives of this City to enter upon
b h
.,;.,.t v entibned property for, inspection purposes
,�-Slgnature (Owner
/Agent)' Date
PERMIT PERMIT
.,BUILDING
DATE 1 VALUATION LOT 01-01- 068 TRACT
JOB SITE r
APN
ADDRESS
PE13111.14". I)EM-34,
OWNER
CONTRACTOR DESIGNER EN (NEER
PGA WWr P.F,.,ffr)7tWr1AL A�RS0M'17014
1)0., NfAF1P:&'_'1M'C0 aUlfffrAL OW17RAM"OR
110 "BOX 1 069
250
I -160)
, .5, 64 :x:500
CIB11".1fl 5825
USE OF PERMIT
V'01,IJINT.AkY
ST RUC'ITIRAlo MODIFIC.A110101
JAN
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VAIAII.A.TJOIN 1.,J L-4,
"TY OF
i MIMMM4V
463.10 C!Oh C)Ir C, Y 0'(7110.114*
F A.11MVE Fit., F ISIOAA.14AR if
C0V3TRUC11I(*.Y0 111E. 101.1,'40 j -d 1 S. 000 Q
M'RC
.410 MOTION filfg - 10 1 -0`04,t I 4N00
-,A;
8*011,TtYrIAL C(X48T1T(rr10)1 PLAN CHECK
$2019.00 1
LEMI
$0.00
TMAJ, PERM' F EE'.1_-'JXT N CIW
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CERTIFICATION OF; C 1 .1 .1
QMPUANCE:,Tdlh6 b6st of.61ui,kriowledge,"all of the reo6rifi6d-��'u6te-s-"S' o-thermse not
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CERTIFICATION IDECOMPLIANCE: To the biist 6f our knowledg'e, all c'
CERTI iihe reported 'v�ori�-.6nleiCcittiirvWso noted;
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11.1pubstanfially.dom es, pqye� plaris !��fic'abd-n'sancl apolicable'siciions'd tifie- b !.e bd coivers
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