0212-139 (MISC)= LIIaNSED CONTRACTOR UECLARAI'ION
114'1I hereby affirm under penalty of perjury. t at l• arri licensed underprowsions:of j
Chapter 9 (commencing with Seotlon 7000)'of Division 3 of the Business and :,.
Professionals Code, and my Uce'nsiHs-in full force and effect 4 1<� �`_,; r.,�A
License #LIC. Class Ems. Date,t
??4381: :may.: #a ? '; C3311IC' " 02AWat
Date N• ;'C�'r� Signatu a of Contractor
�t i ',' v ." t• �;'.... '. ' x
7 i rS,F DOWNER -BUILDER DECLARATION .
I hereby affimi'unde'r penalty of perjury that l am exempt from the Contr`actor's
License Law for.the following reason:,
as'owner of the property, or my`employees with wages as`their sole
Compensation, will do the work, and the structure isnot intended or offered for ,.
sale (Sec 7044; Business & Professionals Code).
(,) I ash owner'.of the property; am - exclusively contracting with,licensed
contractors. to construct. the. project .(Sec. ,7044, Business & Professionals
Code);.
O I am exempt under Section . ;'; BBP.C. for this reason
r` Dated'' Signature of .Owner'
z tri s A1WORKER'S COMPENSATION�DECLARATION
I; hereby affirm •under. penalty of perjury one of the following declarations:
(t), "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.
r I have and will maintain workers' compensation insurance, as required by
Stiction 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:
Cartier " STATI. F"D ; . , -Policy No. 458701
.(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 `
ar'workers' compensation laws of California, and agree that if I should become
subject to,the workers: compensation provie ns.of-Section 3700 of the Labor
Code, I shall forthwith' comply with those pr ISio
Date: '.' r—=�': Applicant ,Z -
Warning: Failure to secure Workers"Compensation cover 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 the Labor Code, Interest and attomey'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. "AI
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, Indemnity
& hold harmless the City of La Quints, 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, andlhereby authorize representatives of this City to enter upon
,,,the above-mentioned property for.insp8ction p rpoc
iea
Signature (Owner/Agent)` ` not
sT
# a uPERMITr BUILDINGPERMITRIF
7I�'�,iSDATE
.�.{...'.f''• •^�4
ar. r"C..
?' ,� VALUATIONS{ �^�s�:it��,i ;c.lpT.,4 .,�1 i.� , � r ��i.
'Fr `*#"��;!- �y�
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JOB tir
ADDRESS �:�Taic. a vc�oor 55 3
APN e:,
,
yy
OWNER ,.'ti
CONTRACTOR/DESIGNER/EN 1NEER iw `
�t3A W= RnMVAMIit�A`°
, I CONS`iR'UCTt4N,i�
4?. -WO CAROLIM COXW `
7%2"C—OANOi CoLdK1'
PALM Alm" . - CA 92211 '.
SAN D?l100 Crk 92111.
(we)560.06" CBLO-1
USE OF PERMIT f
C1EbURALr8TyMING
'
B1, t:_55441,"'55-35% 53.363. RLWAIR HANDRMLS & DZCK
COATiNO --
VALUATION �,890.ao Lt'1
i
I
196TI 1&M COST OF C NS11MCnf0X
4,50A.ClD
PERMIT FEE SUNIUARY
CONSTRUCTION FEE 101-000-418-000 S30,Qt9
r y
i
,
SL1L'-T'O'tlCLucno,;, PLAN C3
$30.00
-'. I}� 1A PRE-P�F�.�xSt
�� rY( G.� �^� ....�---.^2i. �I
�
$0,00' •
...
a vis IYUK HOW
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RECEIPT
DAT EBY
DATE FINALED
INSPECTOR