0304-292 (BLDG)LICENSED CONTRACTOR DECLARATION
I here-- affirm under penalty -of perjury that I am licensed under provisions of
Cha( (commencing with Section 7000) of Division 3 of the Business and
Pro
fes I nals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date _ /?` ���' Signature of Contractor. - ,A.4
OWNER -BUILDER DECLARATION
I hereby affirm under.penalty of perjury,fhat 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).
( ) 1, 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 Y),k,TI P1IN, D Policy No. Ib9iL1A#I'F!1rLz�'Qi
(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.l'should become
subject to the workers' compensation prbvisionsof 4ctiorS.4700 of the Labor
(�pd`e, I shall'.forthwijo comply With thosd provisionst';'_.,
Date: �.j/,...i /,`.•Applicant f f ;�... 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 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
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection>pur4ses.
Signature (Owner/Agent)---'! /�`!f� 3 '� Date �,i
PERMIT# '
BUILDING PERMIT ►..;�:�,
0
DATE VALUATION "6#X%D0 LOT TRACT
X17
7JOB SITE
ADDRESS ]«",ZIG�.�I}�IeAlt'Ctr.�fUfi�
APN
OWNER
CONTRACTOR / DESIGNER / EN INEER '
2' x. 5`3 h2EF`lt.5T2d°n r. r A81,19C.IATION
DY_ 'MAR PA, 3:}"'t:. 00' 4QTRAL C0RTfZ kC 'MY
IBOX. .
25p ?�+:e��E�n1��k�. t":
lA,VU'tA�:yY 90'�fg•L?
�(.
r}(;0601
F.
pp
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USE OF PERMIT
(MIT11-MAL a?t�Jli ll3ri!
19-'726, 'N-1r.M. xiGi..6J3riTARY S'i•RIJC'>'tJRIO, MODIFfCf.'f'TC 101
'd"AUJIAT10111 56,04b.n0
lKffi'!'.M9TM) COST OP.)
PERMIT PER �3�1'Vlt 1t1iiT.4M°d
CO> STI UC'iION �RE .401-000 411't -000 �r'..�{► .
uS'PF.2C: NO MOTYOM FEE - FX—SIO 7 01C700, `.c�41-000
�e y 15 2003
CITY Of" LA QUINTA
F1 A- iCF.. VpoT.
:3 B-TC)TA:t, e:"OMM1'RUC NOW AM) PLW
$44-!,10
1 t9T L PFF4WUr FIX, S FYU NOW
s
RECEIPT
DATE
BY
DA
E INA
INS
OR
S.- L. t