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0301-291 (BLDG)to H N CO W Ouch �wT- 6Zt, coo O. c ~Uja N Z co N ON _U °) N Z 02 rcc Fa -O 0 J J m< O C �Z w5 r-0 R 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 ih bill tofce and MOT. License # Lic. Class Exp. Date Date 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). ( ) 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. fo5jthis reason Date E ' j %.. Signature of Owner <- WORKER'S COMPENSATION DECLA14TION 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: Carriers TY, FUND Policy No. 0444411 UNI')'f3i01004.f,S (This section heed not be completed if the permit valuation is for $100.00 or less). ( ) (.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 ofectic,6 3700 of the Labor Code, I shall forthwith comply with those provisiong Date: 61. ' Applicant s s� Warning: Failure to secure Workers' Compens tion coverage is unlawfud 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 appiicaton 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 fd(r inspection purposes. Signature (Owner/Agent).....,.... , _ !.._... _ ..._._.'.....� h, , PERMIT # BUILDING PERMIT,�:_� DATE t /� VALUATION kXie,Pgt LOT TRACT ., ti - .. JOB SITE �?.�.e���.�..9 E.."mIf:�it�r3.F�:��l�e�9... 4V���'.D.�f'�.I:• i,f�Y�..�. .. .. ADDRESS 14 OWNER CONTRACTOR /DESIGNER / EN (NEEr�R p 1 yl,kY ,g�gN� r e 1° 3 �iJ•R VfF b4 t�.l 'ti�A�DI.S.�L.��S t�d11...19>\DP'C.IVC . g t: 3*_,X�l..�fif/;i:; P_kC41F1C �.�,aa%d.l_U-'-`_PAX t,.',��.I`'YS'14 h�:\�' Vj %x. I f)6 �T�?f�o � f �h�'.11."ic"CTf.1 C110i.'�;i ��3i �1:i"����� '��d�':t� 250 giyv f lJ qy ,7..,j'1{•p"LJ1 ITA • 5:yA 92 ..3 � j-YZhY..6.�j i{.I.` .6j �r 1�.LCi P]':l'�,f'�. !,.A <9-20t�l 5823 USE OF PERMIT ,.I.3 lC' i ! ; 1"1.6f't. Ss1. fj:7;4, .�4• btit>, '�•f�'£. ti S3LL.iPt'Fls.I �" Raf3�-�'Jla-Y,9..Ab,F.•' �.-�'.UtS OF �: ON51.1'E'''SYM4.AN 14)-V KM,:O La INyT RUIC11104 F&K tYT_( 00-1I SAlMi106 S1'I•dONO r34C3°d'IGN F;RO,• kYSID fk,�l_000-241-.000 PPO FEB 0 3 2003 CITY OF LA QUINTAr FINANCE DEPT t '^ 113:P..'1's>.>,.Al.:r i'YfiP.h�'7, M1 1CM0,14 ,.+ 11W X $ l 14.r.! t1 IMSS TUFAL. FERM.11T]CE'S DUE NOW RECEIPT DATE DATE FINALED INSPECTOR