0301-289 (BLDG)LICENSED CONTRACTOR DECLARATION
' '-�ereby affirm under penalty of perjury that I am licensed under provisions of
H-Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W "Professionals Code, and my License is in full force and effect.
chLicense # Lic. Class Exp. Date
cZ r Date Signature of Contractor
�0.rr
J U coo OWNER -BUILDER DECLARATION
UJLU r I hereby affirm under penalty of perjury that I am exempt from the Contractor's
co 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 & Professlonals
Code).
C0 () I am exempt, under Section , B&P.C. f � this r song
0 N Date ;' !i+ Signature of Owner,:,�- _7
L)
d Q WORKER'S COMPENSATION DECLA CATION
p z I hereby affirm under penalty of perjury one of the following declarations:
Lo FQ- O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W L compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q I have and will maintain workers' compensation insurance, as required by
0 0 Q Section 3700 of the Labor Code, for the performance of the work for which this
U')
Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No. G?40fUN1T'Xi S?4Ii
coo Q
g (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 becon2e subject to the
workers' compensation laws of California, .and agree thgf''i ff should become
3 subject to the workers' compensation prJsions of°Sec Ion'3700of the Labor
Code. I shall forthwith comply with thoseZrovisio *,.. _ j- '�
Date _ Applicant > _.._,..,...._.
Warning: Failure to secure Workers' Compensation coverage is unlawful aPrrd
shall subject an employer to criminal penalties and civil fines up to $100,660, 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
dao & 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 representativV s of this City to enter upon
the above-mentioned property/for inspe"ctigA pyr'poses.
` Signature (Owner/Agent):;' :i . • - a' __ ,, Date,: I/
PERMIT #
BUILDING PERMIT
DATE VALUATION $14,0001k LOT TRACT
JOB ADDRESS 7L�n � i,:i' :� i ? ��a$ k' 4 Lia T� .` 6,4_710 -
OWNER
CONTRACTOR/DESIGNER/ENGINEER
AASOC' , INC.
3.)RL YmR aahWEr'.At C-0N'MAf '1'w'>l
3.'.!?..1-s0X ?f.!Fk
25,33 0 U1.1x
vA9.2253
j4lr'L.DfM (',A:,.
CA 5+1221(d
,.
k"tl�ft�p.fi:;y?.•,i+,?�.C.7 s;.'.�zti.�� f��.?.,•es
USE OFF PERMIT
.],��.st'�•.Lt4yV.'.�t:3.:.I.? 1wP�'.I.I.I�.'d'6'`%•
V 0%X*NT.4d:Y
��telt<�3fi?'+<�,I..1t�E7[�I'I;•.1Q.,�.`I°3��1�
�::+21:t,1•>~aa'I�:a?�1 sg�4f3fd.?;1€s Imo'
udm, :Xxl) con" ckk y 4'4.st°fFz!::1a'.:u(711';' n
� �,4:�?�!)•,9?�
PA`LRM"I".MCI SU4.MA.t y
0"OAiFTRUCTION TfIKfes 101<.000,41.':3.000 t9:r .ft�i
JIFRC 1.46 MOTION FEE " :RFI:; D 101-i'�6:) II -•24 9 -000
FEB 0 3 20
CITY OF LA QUINTA
FINANCE DEPT.
813'k- 11444 pi...w o'ehC':.x,,,
$154.4.0
5q /gy
RECEIPT
DATE
BY ':
DATE FINALED
INSPECTOR
J