0108-203 (RPL)U)
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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 # Lia Cl/ass Exp. Date '
t
Date Signature of Contractor
OWNER-BUILDLR DEC A ATION
1 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 Policy No.
(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 wgrkers' compensation prof isio s.`of Section 3700 of the Labor
Code, I sha114for1;f,with comply with those provision
Date: i1 t E t Applicant 1'� ; '-Z•l
Warning: Failure to secure Workers' Imp nsation coverage is unlawful and
shall subject an employer to criminal Ipenalti6s 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
9 1 k r ; construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes. f
Signature,(Owner/Agent) �f Date 4 �r fih:
BUILDING PERMIT PERMIT#
DATE VALUATIGN LOT 13f>t3li. TRACT
10
JOB SITE ”"- APN
ADDRESS
10-142 1,:ORAL LME
OWNER CONTRACTOR / DESIGNER / EN INEER
785105 MEMR52
LAA Qpakarr& CA 922M
USE OF PERMIT
TxCS.REW ALN>. WORri I POOL CvAjMW
74.852. 1ENN0014 PLACE -0
PAIM'DESSW 0k 92211
(760)5681 4M. CRO, 5115
P'OOUSPR, .sU4AAPUW'.V5AP:id1XRS SKA1,L, HE N, P-*'tACLt AT P}S&PL AS`P ER
tAiSF'i:C'P`IM1. POOL.9OUIPWINT ENCLOSURE' N ar rNCLUDED
PCAOJ..FiNDVOR CEPA
25,001.00 Ix
PERWTV) M, SUMMARY
K AN CHEM. HIP, 101-000-4339-318 S1161,90
1'4yNMO3t"',6 KYN FUR 101-000-418-000 '$252.0o
MEC5UNIM FEE -- POOL 101-000-421-000 W.00
Xtfat"•` RUGAL M.8 r= POOL, 101-•000-42(14XIO $45.00
M.IUMB1,40 FRES •" POOL 101-000-419-000 527100
,K.
``2001 �.. 3 PRY -PAID �61�� $10.00
AUG 21
��mIrT.fmi DOD now V511A10
,,n OF LA QUINTA
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RECEIPT DATE �, By DATE FINALED // INSPECT
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INSPECTION RECORD
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Sub Panels
Extprior Receptacles
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