0301-288 (BLDG)s..I hereby'aff Irm under penalty of perjury that I am licensed undeF Oroviilons'of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
4:0LU Professionals Code, and my License is In full force and effect.
:)-M.. License # Llc. Class Exp. Date .
r-.
7C4�3/31/03
LU 733152 BMC
Z /Date Signature of Contractor
OWNER -BUILDER DECLARATION
r- I hereby affirm under penalty of perjury that I am exempt from 'the Contractor's
License Law for the following reason:
Z 1, 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, Bbsingss & Professionals Code).
I; as owner of the property, am exclusiVely contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
cr) I am exempt under Section B&P.C. for his r
u') o6/
04 Signature Date
C\J re of Owner
0 a)
" ECLAR"
<
WORKER'S COMPENSATION D TION
un
Z Me reby affirm under penalty of perjury one of the following declarations:
H'=0 a:
I have and will maintain a certificate of consent to self -insure for workers'
X. Wcompensation, as provided for by Section 3700 of the Labor Code, for the
!0 ED _J _J _J 'performance of the work for which'this permit is issued.
<
�< L) I have and will maintain workers' compensation insurance, as required by
io,Q, - S ion 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:
Cartier,"
STATS FUND Policy No. 04601UNITOON119
,(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 -should become
subject to the workers' compensation provisions 9 Sect' 700 of the Labor
Q B that
,/e
ode,) shalLfortbw✓
th comply with those r A s.
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.
21
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 representative of this City to enter upon
the above mentioned Property I In tion p ses.
ins
S16n,ature (Ownerh_ 7,
PF_HM1 I
BUILDING PERMIT,��,
001w
DATE 7ALUATION LOT TRACT
$14AW00 - 1-1 1
T,
JOB SITE
ADDRESS JUDO:. 6'ejtAhMONS - fin()ALC1='K SLS '-7
APN
OWNER
CONTRACTOR DESIGNER EN (NEER
P" WM UMFHnAL ANW., 111C
DR, MAR kanc tom' R&AL CONTRAMI
P.O. 330X 1060
25:33 S01M1 MAM WCHWAY SM 250
1A Q=T -A CA 92253
CARDUT Fo Y M SEA (.;A 92M
plrqi35=1010 Cal# 5820
USE OF PERMIT
GIMMAL
BLW R. id.824 54-816, 54.11)W, 54-194. VOLUNTARY
STRUCTUPLAI, MODIFICATIONS
14XV.00 J..9
E51WA.'M COSrf OF COMPRU MON
PKRWT 17.9 hPUM-MARY
CONSTRUCTION KE 101-W0.418-000 Wlob
ISTR040 MOTION 1, Elt - RESID 101-000441-000 $1.40
FEB 03 2003 EI
CITY OF LA QUINTA
FINANCE DEPT.
P.141.) )nAw (A. -ink,
$1 14AO
1XS0 PRE -Ml) 1 -TWO
$0.00
TMAL FEIVar 161.111 bKD R011.140W
$154.0
I RECEIPT,
T
DAF
=
BYe�
D
IW/^ IECTOR
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