0201-068 (BLDG)vr. Wr. ,L.Mrl^jAWIV i PERMIT# _
}I hereby affirm under, penalty of.perjury;that l am;licensed under provisions,ofB.U.LLDING: PERMIT �4 .t t'•ic „` +
Chapter 9 (commencing rwith.Sectionk7000)`of Divislon 3 of the Bubftss and �' DATE " . x ,^VALUATION =, LOT _* Y`t r ' f
Professionals Code, and my Ucense Is In. full torte and effect. } ` f- o TRACT t
°<' ' Cleanse # , z ,�tl 3 ;> ,;k Lle Claes Exp. Datenn-
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ADRgsr}331521 Y
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r,.Date ` �� Signature of Contractor tr'OWNER i CONTRACTOR /DESIGNER /EN,•INEER ^ •'
Y,p ro .� �' . �`� ��' < efudl L, .;, ,f �, x}, Y._ 7•_. �? ,r.. ,' i. '. : .,'; - -. . '. :- i,4,,,.
OWNER BUIL DER'DECLARATION PGAWEST Ilk:;M3:NT AL ASSC►C i71v'C. MAP PACM.0 002MW, CONTRACTOR '
911herebyaffirm under penalty, of` perjury that l am exemptfrom the Contractor's i, )BOX I -op. 25.33001.1 C`C)XTf.:FUGHWAY wr'1"E: 250
L'•Icense Law for the following reason > LA t;}i7lAl•: A CA .92253 (ptZ;'tJ1�F �; Y "t`�1'C �� �1 i'r� 9i.0ul
owner, of the property, or myemployees with wages as their sole (F60)564-.950(} t►tia*. 5523.
'compensation "will do the:work; and the structure.is not Intended or offered,.for
resale (Sec: 7044 � Business & Professionals Code) USE OF PERMIT.f *�
aas'owner of 4he property am exclusively;contracting with'licensed
contractors to construct the project (Sec x7044 • BusinesS j&yProfessionals .. v _
t`,
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()I am'exempt under'Section3 F�,��^•�tr:; 88.f?C. for this reason W3. 13f911.U12aCf 3.:th55s; >f0•Sos8t) S?3� &0•S19yt7L13ed'Y.�:RY <°
tDete sts i i iSigynJe�tuyre� lfof2 Ow.�neer w �. �*l ' t3 ST 'i'�f dila Nt�%I�'EC�1'!`T�i�i1:
�re 0* 1A '�' fs �Ss`:Pt*h"'Si•'r t+T-.tv^.• x ' :f '4w .v?' '•l 'y .4, �✓•' - . t=:. , ry,q .�.f ., j`r -r s..l,... �:
Mfr WORKER S"COMP.ENSATION DECLARATION,,
YI1 all/
I' hereby''affirm ,'under• penal of. er u one offthe followings declaration's: :
t,, ty�,P 1 ry' ,.
�<)',L have and will maintain a certiflcate of:consent to self=Insure for. workers'
( is f,L'txA fiION _ xA,(s!'t
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compensation sas�"providetl for by ,Section�3700wof;t6eiCiior Code for-: the + - ` " , 1 Q� � At1 A
' rmanbe of the work for which�this ermit isdssued L_
;aI have and;will#maintain workers' compensations insurance as regwred liy �4
S on 3700 of .the Labor, Code,;for the performance of the' work for: Which ;this a
` permd,IsalssUed Myr workers''compensatlon>`.Insurance tamer &policy„no `are
CaRler •:•fir¢Polley No f�':..r
1"KF¢JAlia ��="mss d �t� :.s 4 j" - O�taotvAlsrui�(i�oZ�� x , :x..� l�vlrxT��.9,i'f� l��ol r�3�1 ����5"Iat:��� r-��i�T 0 �.
y:�rV ,����,ppe �+� p� (�r��q��`[� r .� � �
. T.ir. _� y.{ ,t {ri t • k�+, '.tomf 4N`iH±3{. =h . A.«n'Y 'i` <�'?:' -.L'YL«M7►Qb J7J 1119•Sil7.{.✓4iV MARY
�(, his'seciion.needAa"6e completed'If tlie� permit valuation is.for $100,00 or less). f•' - < / 1'
n( )ul certitylthat in thepeiforriance ofahe work for uvhich this permit is issued, COWSTRUt;T10eJ '
t . 2 til ,000-43 8 000 • $:207, . .
I,ishall not employ any. person in:any manner so asao become'subject-to the �; �3TRC)hiCalACITIIiZ`f FEZ • .RLr,�,lf� i(17 -(I00-24 -000 $2.00
workers'. compensation laws of•Callfomieand;agree that if1l should become;,
subject to the woiicers compensation provisions�of Section, 3700”f the Labor --
40 ;�r ,_ - Y•
``Code I sh I fort with comply}with`th a pr" v)slops r;r3 : _' t' �' a `+
Date )E =Applicant , /�/ r { w ,
Warnin Failure to secure Workers Com a sation: o era a is unlawful and
shall subject an employerrto criminal Penalties and.civil finesup to $100,000, in :t,
°addition ao'the cost of compensation damages as providedsfor in Section 3706 :.y-• v Y
f the I abor Coded interest and attorney's fees
4 w+"Yrtyii'`•iE�;h 3a �`, s�;%i!n'?i3:[�..,,,� ,u Y..; :� r'...
;rIMPORTANT,Applicat$or3�i§ hereby' made to the,Director of Building and Safety, "
for;a3permit subject tothe wconditiosti and Crestnctions ;"set forth fon • his
a Ilcatjon t5 t
1 Each person upon whose behalf this application is made &each person of <�
whose'request'and for whose benefit work is performed under or pursuant to : 0l�3-` XYrAl,,C,'OIT P�'E C� r1:OU—:kWD PLAN- CHI:'�' , `209,00
y permit Issued as a.result of this a licaton agrees to;,& shall indemnify` MOD P,-PAWFEM ��(j
p,5 Whold harmless jh'd Ciry of;LA`Quintei-Its officers agents'�and employees:;
age itof
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CERTIFICATION:OF-,C(jMPLiANCE':T'o-'th'e b4siof'ou'r-kno'w'ie'
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t -';-Od' ""-,'pecdi6ati6ns'diid*ioplicable�s jo— building Tfiki!ite 6oVe'm!.',42.,
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