0301-286 (BLDG)I hereby affirm under penalty of perjury that 1 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 Ai Lic. Class Exp. Date
733152 V31103
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, usiness & Professionals
Code).
() I am exempt under Section B&P.C. r this ye,
Date / " :3 Signature of Owner._.._�
WORKER'S COMPENSATION DECLARAtION
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.
(y,) I have and will maintain workers' compensation insurance, as required by
Sdction 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:
Carrier STATE FUND Policy No. 09601UNIT00494I:
(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 Califgmia, and agree that if I should become
subject to the workers' compensatioq provisions of Sectio 3700 of the Labor
.Code, I shall forthwith comply w(th t bse proyi#ns,,
.Date: 9j IL Applicant—4-,
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, indemnity
& 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, for inspectior)r' rposes.
Signature (OwnedAgent). zDBte/ :.
," BUILDING PERMIT
30°1
DATE
u VALUATION Si4 j LOT S
r� r l 9 (TRACT
JOB SITEPN "
ADDRESS JJxOt3, (* C TAMPCH M IOPJS SHOAL Mr -EV, ,> 4L . 91"
OWNER
CONTRACTOR/DESIGNER/EN INEER
PGA W> ST Jfilt,M'EW11AL. AMWI,114C
DK,1AAR PACIFICGFA!n-Af. C ON`I t+. AiMYa
ID, Dox 1060
2.533 s; OXMI COASTIHOYHWAY 16 250
L.A QUCIVI'A CA .. 92253
CMD* )BY 1'H.I„ SEA CA (12CK)?
E7a))i;35.1010 (IMA, 5823
USE OF PERMIT
(4ENF:l MI . ]aYJli 1 �1 d'L?
BLV(( 6:.94.960, 54-.94& 54.936, 54•9A. Vt LONTARY
STRUCTURAL, MO1: IRCAT'IONS
V AIAIATI(M I4,000i 1.0
ESIxa TM) c().V.r 011 COrfSMUCITON
10MM
PkIRUf, f,1+']hIR 1a"9 h lmd►Lti Y
CONSTRUCTION i-'k;E 1011-000-418-000
S1'1f.UNIO MOTIO•d FEV,- Rle,:10 101-000-2.1!
O
FEB 03 1003 1i
CITY OF l.A QUINTA
FINANCE DEPT.
;8'7 B-•TOT/4L C()2 YrRUM7014 A,N.I) Y-11.t,.1h1pr•'tr74F..�\`� N," .
$154.40
tq"
I.r}1s71�,1:"f.�L+�S�e"'II.S.J'P...l'•!�
e
!P�. rl(.)
T(YYAT,.�'?���1a,� t+�� �;s DUE NOW
$1454,40
RECEIPT
DATE
BY 1,,,,_,,,,,...,_
DATE F A
IN TOR
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