04-3631 (RPL)P.O. BOX 1504
• 5���
78-495 CALLE TAMPICO CV
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
Application Number:
Applicant:
Applicant's Mailing Address:
Architect or Engineer.
.Architect or Engineer's
Uc. No..
TIONS .
V010E (760) 777-7012
FAX .(760) 777-7011
INSPECTIONS' (760) 777-7153
Date:
LICENSED CONTRACTOR'S DECLARATION
1 hereby arum under penalty of perjury that I am licensed uridec provisions of Chapter 9 (eanrthenckV with Section 7000) of Division 3 of the Business and'Prolessionats
Coda. and my Uoense is in 6Al eros and affect
License Gass License No.
Data contractor
ONfNER-BUILDER DECLARATION
1 hereby �tfin' Ander penally of Perjury That 1 am exarhpt from Ito Contractors' State License Law for the odowkng reason (Sec. 703,1.5. Business and Professions Coda: Any
�y Or county that a permit b construct cher, improve. demofisk or repa'a any stuuctum, Prior b Its Issuance. also requires the applicant for the permit to fie a signed
statement that he or she is ioensed Pursuant b the provisions of the Cw*3cWe state License Law (Chapter 9 (conowcing with Section 7000) of Division 3 of the Business
and Piofessios Code) or that he or she is exempt ihae(ran and flu basis for" alleged exempla m. Any victat on' of Section 7031.6
*q apptcard b a dvi penalty of not mere than fire hundred dollars (SSWy17
by any apPScarK Ow a permit subjects
(TU6\ 1. as owner.of the property. or my er pbyees with wages as their sole compensatim will do the work and the strucwm Is not intended or ollered for sale (Sec. 7014..
Business and Prokxsiors Code: The Contractors' State License Law toes not appy b an owner of property who builds or improves thereon: and who does the wok
thkmuelf or herself or through his or her own employees, provided that the inprovenments arenot k Anded or aft W for sale H. Iwweyer, the butfiag a irrrpnohreimhent is
sold within one year of completion, the MW -Wilder will a
have the burden Moving drat he or she did not build or improve f r the purpose of sate.)
U I. as owner of to property. am eWusively eoirlraWnp with licensed contractors to wrtstrud the project (Sec 7044. Business and Professions 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 eortradw(s) licensed p muant to
the Contractors' State License Law.).
U 1 air exempt under Sec. a.& P_C. for this, reason
'WORKERS' COMPENSATION DECLARATION
1 hereby affum under penalty of perjury one of the following declarations:
—I have and will. maintain a certfirale of consent to setons" for workers' commpersabon. as provided for by Section 3700 of the Labor Code. 'or the performance
of the work for which this pemnif Is Issued..
_ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code. for the performance a the work for which this permit is
;ssued. MM workers' compensation insurance canter and policy number are:
Cartier
_ PO" Number
I certify riot, in the Perfommance of the work for which this Permit is issued. l shad mol empty any person in any mamer so as.to become subject b the workers'
compensation laws of Caiomia, and agree VOL if I should become subject to the workers' compensation provisions of Seclion 3700 of the Labor Code. I shad
orthmwtth comply with those provislorm
Date Apptiwnt
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SFULLL SUBJECT AN EMPLOYER TO C
CML FINES UP TO ONE.HUNDRED THOUSAND DOLLARS ($100.000). IN ADDITION TO THE CES AND
OST Of COMPENSATION. DAMAGES AS CRIMINAL
FOR IN PENALTIES
SECTION 3706 OF THE -LABOR CODE, INTEREST, AND ATTORNEY'S FEES. .
CONSTRUCTION LENDING AGENCY
1 hereby affirm under penalty of perjury that there is a constrdim lerndng agency for the performance of the work tot which this permit is issued (Sec. 3097. Civ. C.).
Lender's Name
Lenders Address
b e
IMPORTANT Application is hereby rtr0dthe Director of APPLICANT ACKNOWLEDGEMENT
Each Person upon whose de to this BukfaV and Safety or a permit subject b the conditions and restrictions set font on this application.
issued as result of dins a application Is made, each person at.wh ose request and or whose benefit work is pedommed under or pursuant o. any permit
Pplication. the owner, and the applicant, each agrees to. and shad. defend. indemnify and hold harmless the City of LaQmnkda, Its
officers. agents and employees for any ad or dmissim related to the work being performed under or lobwing issuance of this pemtL
2- Any permit issued as a result of olds application becomes null and void if work is not commenced within 160 days from date of issuance of such permit, or
cessation of work for 180 days will subject permit to cancellation.
I cer6y that I have read this application and state that the above kdonnation is coned. I agree to comply with all city and county ordinances and state laws relating to
construction. and hereby aut ado representatives of this county to enter upon the above-mentioned property inspection purposes. building
Date �/—Ontumpplicant or Agent):