0006-004 (RR)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in,full force and effect.
License # Lic. Class Exp. Date
72 3 C39 :n 08131/2(
11
ate t O. Signature of Contractor
OWNER -BUILDER DECLAR ION
I hereby affirm under penalty of pedury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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).
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ) 1'have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
CamPr STATE nMD Policy No. 2W gp UNIT $12
(This section need not be completed if the permit valuation is for $100.00 or less).
( .) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject. to the workers' compensation provisions of Section 3700 of the Labor
Cod sh I fo hwith comply with tho ovisions.
D e: _1;, Applican _
Warning: Failure to secure Workers' Compensation coverage is unlawful and
sha-Ir bject an employer to criminal penalties and civil fines up to $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.
IMPORTANT Application is hereby made to the Directoi of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
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 issued as a result of this applicaton agrees to, & shall, indemnify
&'hold harmless the City of .La Quinta, its officers, agents and employees.
2. Any permit 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.
I certify that I have read this application and state that .the above information is
correct. I agree to comply with all City, and State laws relating to the building
constr ction, and hereby authorize representatives of this City to enter upon
Zave-mentioned property for inspectio p poses.re (Owner/Agentl Date
'�- BUILDING PERMIT PERM T#
q)ATE ,VALUATION LOT .. -OW TRACT '
>C11AIO=
JOB SITE
APN
ADDRESS
80143,11110149 PAI.>aiI C (ZX DIUM
- -
OWNER --"`— — -- '— '"
CONTRACTOR/ DESIGNER/ EN (NEER
MONARCH MAMA
IEIIE MAPACMC Ro OFW43
42.600 CAR01M COURT 9U.lTE 101
40) Vii' 25M MW
PALM DEMT CA 92211
UPLAND CA 91794
(909)"2-6611 0B,I1lI 3602
s
USE OF PERMIT
1=
tALBiJ7LJ7IIdC1
It OOF ONLY-R1I; ChIr9 NXIS'Z' 0 WOOD SHMOLES& REPLACE VnTH
D9CAA TILE ROOF SBO I&R.34"' CLASS A Ing RAiriwo owy,
VALUATION IS
XSTMATED COST!' OF LO.PTSmucnoN
11;;0MM .
MOW FRE SiTAD A,RY
R.YROOF RE .- 101-000-418-M . ' __ Mop
SUB -"T'O'TAL C0)4=UCn0X AND PLAN CBE -CK
530.00
IJ= PM -PAID FM
80,00
TOTAL PE'MMT FM DUE. HOW
$XAU
RECEIPT
DATE
DATE FINALED
INSPECTOR