0304-292 (BLDG)LICENSED CONTRACTOR DECLARATION
I her affirm under penalty -of perjury that I am licensed under provisions of
H Cha( (commencing with Section 7000) of Division 3 of the Business and
C14.U�J Profess, nals Code, and my License is in full force and effect.
O ch License # Lic. Class Exp. Date
LU
ZO G ."Date _ . t%�6ignature of Contractor
J U 0 'OWNER -BUILDER DECLARATION
WUJ I hereby affirm under.penalty of perjury that I am exempt from the Contractor's
m License Law for the following reason:
Z ( ) 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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
C0 () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
O�
0- Q WORKER'S COMPENSATION DECLARATION
p Z
cc hereby affirm under penalty of perjury one of the following declarations:
LO O ( ) I have and will maintain a certificate of consent to self -insure for workers'
X W y: compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
M Q U () I have and will maintain workers' compensation insurance, as required by
Q �Q Section 3700 of the Labor Code, for the performance of the work for which this
0)F<:
— permit is issued. My workers' compensation insurance carrier & policy no. are:
,It Z Carrier FVJ" ,D Policy No. fkI M3)zT7tF't'f!ffi %4 i
ob Z)
r -a
J (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.11should become
3 subject to the workers' compensation provision fbf3700 of the Labor
ctior%
Cpde, I hall'forthwito comply with thosd provisions,;_ ..
.. ,. " i r:..
Date: t r/ " . /r. -Applicant .._.__j..._.._•• �
Warning: Failure to secure Workers' Compensation 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 riot 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
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned_ property for inspeefiornpur6gises.
Signature Owner/A ent l ` `�6 /l ( '+, Date
BUILDING PERMIT PERM'G.V4 :91
DATE VALUATION i�iT�j Jim LOT TRACT
"
/ �t
ADDRESS11:.�.I)a. 05 a LYM PIA Ffli:.109 0.1mi KIN JOB
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER '
Tr' rl+:.W Eass``.f IRMAT.�WT'I.A A,S ?C5('–L-VTi )34
DY.. 4AAR PA,C::Si"C L 0;.f<'.RAL COYvf'1'. wkC tY,:9:
FIA BOX � IMO
s �+a�liJst�t" ("A 1211S3
:..14k 9200;
5023
USE OF PERMIT
GMIJURAL 1:tT rt' 1ING
1 U J.
"�•�,i�'a"E'•`A'�"L�. tiiC•L1J'Fi'iATtiY 5'T`�;::fC^'(J�ATa ItiTOT3TT�3d!;.F:`tiTC�t��
VAIAMNTIOIN
EYESIAT1) COST OF COAf 1R,1R7UA`Eq
17YL11 MIT F n IST MM ARy
C`•ow- r,PUCTIO1411TS i01-000-411440
5'PRt;""+ld� i1riC3�"fOtd �F - k� aJt3 'f tJl ••i�0i'•�fi l-Gii�.i h!.bfi ,
15 2003
CITY OF LA QUINTA
81:'B=C()TM, f;'CDMiJ.CdGC`• a0.9:AN"9 PLAN FM'uX*X.
$44 t. 10
?.N. E1 PDE -PAID
C. --7
RECEIPT
DATE-
BY
DA
E INA D
INS
OR
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