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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 offoct.
License # Lic. Class Exp. Date
7 33 15 13 IVC
Signature of Contractor.
OWNER -BUILDER DECLARATION
313,1103
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. 704.4, Business_.&.Prfessionals
Code). f f° X
() I am exempt under Section B&kC. for this r s n
Date t '� Signature of Owner "' t
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.
I have and will maintain workers' compensation insurance, as required by
Section 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:
CarrierTMJ` E, a 4UNI ,) Policy No. 0+160110'1) JTIYO(V1q
(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 agre�ePat if I should become
subject to the workers' compensation {ovisions ofectigfi 3700 of the Labor
Code, I shall, forthwith comply with thole proyisiliFis. .
Date: �° ; Applicant ` _ 1-`• ..c ....
a
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 tha•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 f inspectioryburposes.
Signature (Owner/Agent)'` f ,/ -.� '' Date
BUILDING PERMIT
0101-2:6A
DATE f'- /' VALUATION u InT TnACT
JOB SITE
ADDRESS 01.0Q.4 Cf11A ID.NS - S:91[.as1 X, CZ i. 9�. S757
APN
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OWNER
CONTRACTOR / DESIGNER 1NEE�R
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USE OF PERMIT
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S i Et.> zC TUPAL, fyi00100�f 10116
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FEB 0 3 2003 1
CITY OF LA QUINTA
FINANCE DEPT. .
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TUTAL
RECEIPT
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