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LICENSED CONTRACTOR DECLARATION
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 effect.'
License # Lic. Class Exp. Date
71 r j fsit li ��
10
ft}�r�,
Dat /</. Signature of Contra--~
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury�tha"tI am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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, Business & Professionals
Code).
() I am exempt under Section , B&P.C. for this reason
Date 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.
()C) 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:
Carrier Policy No.
I'r�'•tiTl4.0413& CO. 2W21lS010I
PERMIT# - 'CONTROL#
I (/ BUILDING PERMIT 96t2.149 4547
DATE ! �3 / JCf VALUATION 006.E 37 (g) LOT : f �j i TRACT 239354
JOB SITE 5
ADDRESS 444 APN I t►43# � #1�S
OWNER CONTRACTOR / DESIGNER / ENGINEER
T1114 0.1ICY Er111101i Ct:)P.l&1t.1NITI€, "I
SAN AFRNAWINC) (-'A 92408
SAN'SIMINARDINO CA Q408
f)� tFstrtif2t}7 (.:E3�Lf 21210
USE OF PERMIT I3VNJANIJ,N .NI;UJ_LA c AStiO IA A ES
Stet? M59 PASSFRO A*Vk;. '
(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 agree that if I should become
subject to the workers' compensation proy.sions of Section 3.7.00 o 1 he"Labor
ode, I shall?fort�,With comply with th s€provisiogs.
Date: f/ / - Applicant
Warning: Failure to secure Workers' Cormion coverage is unlawful and
shall subject an employer to crimi a�nalties 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
1. Each person upon whose behalf this application is made & each person atn:
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
t
& 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
11yCR.L.A1QUWTANCd TU"
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PLAN i F411C7K.l"12&1 fil%1)I+i'"'Fit) F40R MIJf,'1V1,11.4141A 0V NANW, PLAN
IF"0l<CflJPX1 f0 NJI.0 ► �
O'ARAt_4hJC;AI<i'C))t.'i' •120.1X1 Sl'
IMAITIE10 'C"081, or CON -17=11171, ON
PF30011' VEIC ISIUM i<iEiky
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101.000AWAV t3- AV
4 M0
KAN C"?4-1K, PET
"N -W-439-318
it ISwiil 4fCAL i`�MS
101^000 4,11,1 -'WO'
ar2.G"1`1' c,1. sit., 8-
161', -OW -420-000
a .941
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101 -OW -419-000
$l'�'t.Stt
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1014W-.24,11_000
GRAVING
1NP,i'}A,`VfU01M
22.54)00-44.E-342
ART tN PUf33X.i4: i?t:,f1.CES t S)
701-000-255.000
$16-59
® AS fiIi C,°Oi' S 1"F'zCiCITON AND PLAN CHEM
Fr_ LESS 111RE,-PAIDITES
DEC 3 U .1996 TO'Gvl', PETWIT Fns ofw NOW
CITY OF LA QUANTAL J
the above-mentioned property for,inspection,purposes..
/ RECEIPT DATE
/Signature (Owner/Agent) ''-�'''" Date 7_41 Z"2
DATE FINALED INSPECTOR
106,07.0
$3i636.79
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