0006-002 (RR)LICENSED CONTRACTOR DEC LARATON
I hereby affirm under penalty of perjury that I am license 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.
U nse # Uc. Class Exp. Date
647V3 C39 0$131/3(
Date Signature of Contract
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of. perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, 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.
() I 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:
Carrier STATU FUND Policy No. US- 00 11101T 812
(This section need not be completed it the perrnit 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
subje •t to the workers' compensation provisions of Section -3700 of the Labor
0 1 sha fo hwith comply with tho rovisioR .
te: Applicant
Warning: Failure to secure Workers' Co pensation coverage is unlawful and
shall subject 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 Director 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
constru ' 6n,• and hereby authorize representatives of this City'3o enter upon
the ve-mentioned property for inspec •onurposes.
Signature (Owner/Agents Date
FT
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
$?h�0,ti0
JOB SITE
APN
ADDRESS *DJ[80 W F CW= DR= 4
OWNER
CONTRACTOR! DESIGNER / EN (NEER
MONARM N(MMOMAElTr
SIERRA PACMC ROOFING
42.600 �CAR0INL� COURT 13 101
400 EAST 25TH SST
PALM DE. CA 92211
UPLAND CA 91784
(909)982.6611 CNA $602
USE OF PERMIT
t,1F.itAL BtiII.I�71�C1
� a,:
RXP001? 0MY-REMOV19 FMMING WAOD SHIM =& RL►PI ACE WITH
DECRA TUX ROOF (IC80 8R, .34" CLAN A I= R.ATMO ONLY'.
VALUATION LS
RunMATM COW OF CON91RUCMON'
11,0 0.00
P'i Ri4� FEE 9Uh9 fARY
REROOF FU 1017000-418-000
SM -TOTAL CONORiTMON AND PIAN CgWZK
$94.00
LWS PRE-PAU) FM
$'0.00
TOTAL PERMrr FM DUE NOW
X.
MOO
RECEIPT
DATE
B
DATE FINALED
INSPECTOR