0202-293 (RER)I Uereuy dM1111 Unuel penally of pepum u
ury �at I am under provisions Ot
FN— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
C 5 ch License # Lic. Class Exp. Date
LU T-
Z
c Z t` Date Signature Signature of Contractor '
(�D 0
J
0 OWNER -BUILDER DECLARATION
HaW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
ch () I am exempt under Section , B&P.C. for this reason
N Date Signature of Owner
ON
G"
a< WORKER'S COMPENSATION DECLARATION
o Q I hereby affirm under penalty of perjury one of the following declarations:
U) H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W l6 compensation, as provided for by Section 3700 of the Labor Code, for the
Om J Q performance of the work for which this permit is issued.
Q *�). I have and will maintain workers' compensation insurance, as required by
O 0 Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn Z permit is issued. My workers' compensation insurance carrier & policy no. are:
'7 Carrier Policy No.
n
STATE FUND 04601UN1'i'N"415
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 I should become
subject to the workers' compensation provisions of Section 37,00 of the Labor
3 . Code, I shall forthwith comply with those provisions.
Date: 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 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, indemnity
& 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
j the above-mentioned property for inspection purposes.
( Signature (Owner/Agent) �f ` Date
auiLviivu, maim i
DATE VALUATION LOT ()202.•.293 TRACT
-
JOB SITE
ADDRESS C 4— �l f
APN
SHOAL C;RKK'K J
_
OWNER
CONTRACTOR/DESIGNER/EN INEER
1'"A MEW RESIDENTLA% Ab`iEW
DEL MAR PACIMC Cir'F.,%iERAL CON"i'12,IsC'L1.)1
Y:1,0150X1060
X5 ,3 ;?1:rII=1Cf)s' C 11fiLliIVAY�t'r'.6g0
LA QUI)I L A CA 92253
CARl:8WP-Y 1r3i SEii, CA 92007
(760)5&1.9500 car a'3 �Ei1:3
USE OF PERMIT
MD3(M11LA 1FAAJ3
HUILDINO E8- 54 -219,54 -?l 1, A VOLI.YN 'ARY Vit19L:'f'URAL
MODIFICATIONS
VALUATIO)4 eltUO'I.DG is
1a:ur'x'MATEM Coly.r 011' CONSc1111CMON
1.(i,9M.0o
t,i�ir�8'f.!#f1i"Cta�1! 1-u 101-.000.411.4.000
STIRI NCI MOTION FY?.E • RESID 1 tf 1 4)(A)-114,1-.000
titIM-ECa'1'AI. CC: N91'RUC!,71014 AH i`S
j S (")0
PRE-PA11)
$0100
RECEIPT
DATE
BY
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