0306-374 (RR)H
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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
70940 C39 me 1180/2(
Date 4 414 ' 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.
(�?) 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
p4rmit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier ST.ATF FUM Policy No. 16409-54--200%3
(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
Code, I shall forthwith comply wiiq those provisions.
Date: :zr4 •. Applicant—
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 subjebt 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.
,ture (Owner/Agent) ^�-'""'� ' Date
,,Signa
PERMIT #
By_ jLDING PERM0306-374
DATE VALUATION LOT TRACT
*
JOB SITE
ADDRESS f'"'r
OWIUWOOD
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
PGA Wf 3. F,9, MMi`1LKL r' 232) ';I.Ft~'7'i ON
fMIMALD R00FIN0, INC
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=t5f)G PF..R¢:II 3T
PAM DESERT CA 92211
AN010 CA, 92201
,60) -9869 CB119
USE OF PERMIT
(1.1 M.€ L 13Ii)IJ31UG
RE -ROOF WITH POLYUREY'FfA-NE f/' )A..M &COAYING
VALUATION 1.3
ESTIMATKD COST OF CONS'M'17MOR
k8.,:mav
PERK' FEE SUAW ir.Y
11J ROCIF FEE 101-000-4-18-000 S30.00 .
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