0301-285 (BLDG)t!. I hereby off Irrh under penalty of perjury.1hat I am licensed Under provisions ofChapter*9 (commencing with Section 7000) of Division 3 of thi Business and'LIJ 733152 B MC10 �Pfite Signature of ContractorI hereby affirm under'penalty of perjury that I am exempt from the Contractor'sLicense Law for the following reason:1, as owner of the property, or my employees with wages as their soleCOmpensatlon, will do the work, and the structure Is not Intended or offered forsale (Sec. 7044, Business & Professionals Code).,I_ai owner of the property, am exclusively contracting with licensed'Icontractors,to construct the project (Sec. 7044, Business & Profs sionalsC44 Dal61 Signature of Ownec, -../fr4:`e -WORKER'S COMPENSATION DECLARATION1, 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 theperformance of the work for which this permit is issued.I have and will maintain workers' compensation Insurance, as required bySeldtfort 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:Ise on need not be coiinpleted If the permit valuation Is for $100.00 or less).eijl, I certl 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�',�iorkersl compensation laws of California, an agree th t I should becomew os'.Code, I shall forthwith comply Ith th4 a hpr IE nApplicant..Warning: Fa ure to secure Workers' Compensation coverage Is unle and.,shall subject an employer to criminal penalties and civil fines up to $100,000, Inaddition to the cost of compensation, damages as provided for In Section 3706x V the Labor Code, Interest and attorney's fees.IMPORTANT Appllcatlon.19 hereby made to the Director of Building and Safety11 Ifor,* a permit subject, to the conditions and restrictions set. forth on hisi application.b' Is made & each person atEach person upon whose shelf this application�,,Pw ose request and for whose benefit work Is performed under or pursuant to.& shall, Indemnifyany permit Issued as a result of this applicaton agrees to,",& 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 suchpermit, 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 Iscorrect. I agree to comply with all City, 9,nd State laws relating to the buildingconstruction, and hereby autPorize reYesen tives of this City to 4 enter uponDK
DATE /`A',"WAOi"%'�
z:214 LOT
JOB SITE
OWNER
CONTRACTOR/ DESIGNER /ENGINEER
P101 BOX 1060
2533 SOUM MMTWrjHWAY STE 25.0
1A Q7J1NTA CA 92253
(_qA10:YWVDY'fH1h'SRA CA 92MY7
USE OF PERMIT
STRUCTURAL, MODIRICATIONS
VALUATION LS
EVITWITID CM OF CONSIMIXT171170N
10M.00
CONSTRUCTION FRE 101-OM418-000 $153.0
rrFEB 0 3 2�003
ITY OF LA QUINTA
FINANCE DEPT.
i.,aw
S0100
RECEIPT
DATE
B`Y
DATE FIN
R