0308-370 (RR)H
N t)
W
O C
ti W
C Z
� o
W
W
I— a
co
Z
CO
LO
N
O�
UQ
Z
Lr) Hcc
O
X W �L
M <
OU
fl 0)
v _Z
co 5
n CY
J
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
`i [1 4Ei C39141C 11/30/2C
Signature of Contractor
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.
(" 1 have and will maintain workers' compensation insurance, as required by
Se' ion 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 STATE RM Policy No. 1640954.203
(This section need not be completed if the permit valuation is for $100.00 or less).
() 1 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
Code, I shall forthwith comply with.4gose provisions.
Date: ` ; Q Applicant_M
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 subjedt 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 purposes.
Signature (Owner/Agent) Date•'
B I�•DING PERMIT PERMIT#
DATE VALUATION LOT. TRACT.
JOB SITE.
ADDRESS 7Sa_730. 74�i.Ig0RTHW, 0D_
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
POA VM- S`f RMDEI3rfW., A&SOCIA,LION .
MdERALD ROOT-Wa, 1W.
42.600 CAROLDW COI7Kr
aII3aLyCtO PF.PsC;J� ��.
PALM LSI+,SM C.A.92211
INDIO CA 92201
(766)347-9869 C"I3LO 5978
USE OF PERMIT
0KNER ell, DTJU I DJG
R&RCKV WITH PQ1. 'UTUTHANX FOAM Cr.ATMIU
a?E2MTr FEE SUA RY
RIrI OOF FEE,
Lt r�
�U0. 2003
. � 29
CITY 0"i" -A- Q ;TSTA
SM. -T(.,Y[A[, COMM Ri.JtMONAND PZ.ia N (SWIM
IES PRE-..PADMES
;J,Of7
I'MAL PFRMTFFY.S DULP Y.g0W
$30M
RECEIPT
DATE
BY
D E F ALE
INSPE
I