04-5183 (BLCK)P.O. BOX 1504iVOICE (760) 7.7.7-7012
79-495 CALLE TAMPICO : FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153-
BUILDING
77-7153BUILDING & SAFETY DEPARTMENT
Application Number.
Applicant:
Applicant's Mailing Address:
Date: .
Architect or Engineer
Architect or Engineer's Address:
Uc. No.:
BUILDING PERMIT DECLARATIONS
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm under penalty of perjury that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of thaBusiness and Professionals
Code. and my Lken is in full force and effect.
License Class ��. $ 3 License No. /2
i dW •
L5#co(*act0r OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors' State license Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
city or minty that requires a pemtit to construct alter, improve. demolisk or repair any sbuckm prior to its Issuance, also requires the applicant for the. pemdt b file a sOied
statement that he or she Is icedsed pursuant to the provisions of the Contraction State License Lew (Chapter 9 (carrmerwing with Section 7000) of Division 3 of the Business
and Professions CoQ ) or that he or she is exempt therefrom and the basis for the aleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects
time applicant to a civil penalty of not more than five hundred dollars (=500).);
U 1. as -owner of the property, or my employees with wages as thele sole compensation, will do the work and the structure is not intended or offered tarsal* C-ee. 7044,
Business and Professions Code: The ContractorsState License Law does not apply b an ow. mw property who builds or improves thereon, and who does to work
h intself or herself or through his or her own employees, provided -that the improremefftare not intended or offered for sate. k however, the building or Muprovement Is
said within one year of completion. the 0wFWr budder will have the burden of Vwft that he or she did not build or improve for the purpose of sale.).
U t as. owner of the property. am G=kWvety contracting with loaned contractors b construct the project (Sec. 7044. Business and Professio s Code: The Contractors'
State License law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a conbador(s) licensed pursuant to
the Coniractos' State License Law.).
U 1 am exempt under Seo. BA PA. for this reason_
Date Owner.
WORKERS' COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:.
_ I have and.wW maintain a certificate of consent to self -Insure for workers' compensation, as provided for by Section 3700 of the Labor Code. for the perfomiance
of the work for which this permit Is issued.
have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for wthkh Ods permit is
Q• My warmers' �hpensation.irisuradce carrier and poI'�r�y�er are:
Carrier P 4-tAAJ _"J Policy Number Mi S/(o/9/Y� �//fie
_ I.oerwy 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 b the workers'
compensation laws of California, and agree that t I should become subject to the workers' compensation provisions of Sedan 3700 of the Labor Code, I shall
forthwith comply with those .
Date j r LN
Applicant t
WARNING: FAILURE TO SECURE WORKERS' CC"PENSATION COVERAGE IS UNLAWFUL, AND SH ALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS (S1oo,o00), IN ADDmON TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
1 hereby affirm under penalty of poijury that there Is a construction lending agency for the performance of the work for which this permit Is issued (Sac 3097. Civ. C.).
Lendees Name.
Lender's Address
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject b the conditions and restrictions set forth on this appicatiori.
1. Each parson upon whose behalf this application Is made. each person at whose request and for whose benefit wok is performed under or pursuant to an
Issued as a result of this application, the owner, and the applicant, each agrees b, and shall, defend, inharmlesst
emnify and hold harmless the City of La Quinta, permit
officers. agents and employees for any act or omission related to On4ibrk being performed -under or,following issuance of this pemilL
2 Any permit issued as a result of this application becomes null and void t wtxk is not commenced within 180 days from date of Issuance of such permit or
cessation of work for 180 days will subject permit b cancellation.
m
certify that I have read this application and state that the above infoaticorrectb comply with all city and county ordinances and state laws relating b building
construction. and hereby authorize representatives of this county to thea for inspection purposes.
r ,
Date �� Signature (Applicant or Agent):