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0301-287 (BLDG):C0 fV N 'r W sm M t Q In{� Z Od F� W a. U) Z wcu InN%..lvn uc%..LMnAIIVW 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 # LIC. Class Exp. Date ', 733152 B HIC 3/31/03 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). ( ) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business & Professionals ' Code).. LO,1 am exempt under Section B&P.C. or this re s o � Date /° '%'s% ? Signature of Owner•-. -� d Q WORKER'S COMPENSATION DECLA A ION Z I +hereby affirm under penalty of perjury one of the following declarations: 1.-; 0 t O 1 have and will maintain a certificate of consent to self -insure for workers' X W compensation, as provided for by Section 3700 of the Labor Code, for the 00 J Q ; performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by jQ �. Q ,Shdloh 3700 of the Labor Code, for the performance of the work for which this CL o) permit is Issued. My workers' compensation insurance carrier & policy no. are: "OM1'•— ;Ca►►ier SCATS111�i1) Policy No. f)At?Glll2i'1T(14►OS�AIti t}: g (This section need not be completed if the permit valuation is for $100.00 or less). 1 () 1 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 f workers' compensation laws of California, and agree t & if I should become subject to the workers' compensatio provisions 0 • Se tion 3700 of the Labor 3: Code, I shall forthwith complywith ose pro iSio 1, bate: "' �; jApplicanf r.... r J.. . r Vit' Warning: Failure to secure Workers' Co qensation coverage is(-Aawful 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. 1PORTANT Application is hereby made to the Director of Building and Safety ,r a permit subject to the conditions and restrictions set forth on his )plication. 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. sertity that I have read this application and state that the above information is Irrect. I agree to comply with all City, and State laws relating to the building mstruction, and hereby authorize representative of this City to enter upon e above-mentioned property f9r inspegtio�pur oses. gnature (Owner/Agehi)'•-li� PE BUILDING PERMIT RMIT-� `owl ., DAR" rp"LUATION' ' $14,00 Fi LUI IHACI i JOB SITEAPN ADDRESS ' EIMO. 7 CWA?VM0M- 5U,0AI'a C2=1< 5+-918� . , ' •k "., OWNER CONTRACTOR / DESIGNER I ENGINEER PGA'liWT RMWMT11M, A SOC., INC" TJF.1, MAR PAMIC MJF COMMWMI P101 Box 1060 2333 0©m,11 CotoT'w7a.m.AY ria. "0 TA QUANTA (:A. 922.53 (Afi:f:0TBY 11R. 8HA CA 92007 (76())635.1010 GBIX 5523. USE OF PERMIT GF�I'l�AL.13L1TL,L>£t�f C t7Ld70. h 51.41.7., 54.9K 54.9411 54.876.'V'fti.UW7'A1?Y 5713,IpttTUR.AI, ME>f)f1;`it;.t�i'IC►1�;T V.R1,t,1.A'T'ICitd l9,t1l1(t,f�0 !,v COST Z>'F C 011ST.'}2'lft,"T.SCJS 14,000M TT 1ry'/yyyy,,pp�� ��yyLL'•yy,, ,,�[Ytp7•y S, p �.Cy„�SyT'W'A771) E*�6C3Ya.ir A•.er E7 lf.�C�:itl.�41'.R C01,4S'1'tiUMION FEE, 10)-000-418-000 fi1'�,p0 '"I'KCaM0 M OTIC) -N 1+L. ,. RESIF) 101-000-24.1-000 ?F FEB 03 1003 CITY OF LA QUINTA FINANCE DEPT. 81JB=.l0'f,AL. C90Ai'8'd I:LUM10H AM) :PLA14MTC'1't . _ ==1 ' ` X 154.40 Xa+ FjT`f�-Ta�lf .I�? ..9 $0,00 (Y.W, YERMH T;•: TS DUE 1*iM 0'.4AO RECEIPT DATE f ! BY DAT I L INSPE R