0301-286 (BLDG)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 # f Lic. Class Exp. Date
7.143152 .1:3 ITC
Date Signature of Contractor
3/11/03
OWNER -BUILDER DECLARATION 11 ,.
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, usiness Pr fessionals
Code).
() I am exempt under Section B&P.C.r
this;e
Date 3 Signature of Owner -__11/
WORKER'S COMPENSATION DECLAROION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain acertificate 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
Sd6iion 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:
Canier STATE MND Policy No. 04691I.MIT0009415
(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,
shall not employ any person in any manner so as to become subject to the
workers' compensation laws of Calif7mia, and agree that if I should become
subject to the workers' compensation) provisions of Sectlo 3700 of the Labor
.Code, I shall forthwith comply, w(th t se proyi ionsz. /
Date: 7j ' Applicant 1
Warning: Failure to secure Workers' Compensation coverage is unla ul 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, 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#or inspection)/ rposes.
/Signature (Owner/Agent)
BUILDING PERMIT Yin
DATE VALUATION` w+4 d LOT 4.
.00
JOB SITE
ADDRESS MMG. 6 cIIAWIOIW - SHOAL G =/C 55< -92;
OWNER
CONTRACTOR/DESIGNER/EN INFER
PGA WFgT Pte' IX rLh L AMC., IN(,"
DIa.1 Ail PACISiC OF:NIRAL Cf3.NTRAClY
RID, BOX 1060
2533 SC)1J M COA,tTMUGHWAY WE 240
LA Qi.6l l -A, CA+. •• 922.53
CAVKr0W)BY TIE SEA CA 92W?
(760)(135-1010 C' MA 5573
USE OF PERMIT
(:11:NIi ZA11: TWILDING
[iL;00- b: 54.913th 54-94ty 54.936, 54.922. VOLONTARY
KTRUCTUR.A.t. MODIFICATIONS
VA1,VATION 24,f=! U,ttt; lxr
PkIk i:1.':i' PER &ftTM11n:MZY
COMTRUCTIO)" FEE )01-0+00.418.000
STlz•tYNG MOT JOH FEK- ki<::ID 101-000-2-11-000
D A D
FEB 0 3 2003
OF LA QUINTA
CITY
FINANCE DEPT.
3T1E1-TOT.PT, LXY2d':Mt11C'.',1TON ANty l'.':IAII C-34RA49.
$1.54-40
-PFX-F'AA,T.�:'f MEM
$ROO
T(Y_'AL PIMMI.'1't}'EM DI TE NOW
$04,40
RECEIPT
DATE
BY
DATE F A
IN TOR
FAI