0212-138 (MISC)LICtNSED CONTHACi'UH UECLAHMION
11
hereby affirm under penal j of perjurythat I'`am.licensed under'pro 61bris�, 14111 of �
Chapter 9 (commencing with. Section 7000)' of Division 3 of the Business and y s
Professionals Code and my License Is in full force and effect C :fxf, �' ; t144,
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,re License # Lk: Class -; c'" .41 Exp: Da� +� '! ..,.
, .
. '� . h, .T'•< yc�,y.E.
*, 774382: W_ �� ,. �� N $ c33 Hilo
1; ,' ' :.. t7, "jw..,,,f •.
Y.
Date � ^ ' "Signature ofYCoritractor ^`
fir' - r i
u ,i YKr j siOWNER=BUILDER DLCCARATION
I hereby affimi'under penalty»of perjury that I am exempt from the Contractors,
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 & Prof essionals'Code).
'!`(�,),'A •as4Owner•of.the property,"am exclusively contracting',with licensed
;,contractor8'to construct the project (Sec. 7044, Business &i,Professionals
O� I am exempt`under Section nB&P.C: for this reason
},Date 'F ;" ' Signature, of Owner- '�- ; t, t' # "i;r
+16 WORKER'S COMPENSATION DECLARATION
.,Jhereby affirm under penalty` of er u ' one of the following de6larations:
{(2) I have and will maintain a certificate of consent to self -insure for workers'
s'icompensation', as'provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is Issued.
1 have and will maintain workers' compensation, Insurance, as required by
Station 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::
S'TATK FUND Policy No. .:1416M ,
t? (This section need not be completed If the permit valuation is for $100.00 or less).
. ( ) 1 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'.,'
s subject to the workers' compensation proy7tpns. of • ection 3700 of the Labor
Code-, I shall forthwith comply with those�rovisio
`Date:_., Applicant
f Wernirig: Failure to secure Workers''`Co pensatioh-coverage is unlawful and
shall subject an employer to crirrfi'nal penalties and civil fines up to $100,000, in
's'addition to the cost of compensation, damages as provided for in Section 3706
i of the Labor Code: Interest and attorney's fees.
IMPORTANT` Application is hereby made to the Director of Building and Safety
r,.for a permit' subject to the conditions and restrictions • set forth on his
application.
Each person upon whose behalf this application is made & each person at
i. -whose request and for whose benefit work is performed under or pursuant to
. y; any permit issued as a result of this applicator agrees to, & shall, Indemnify
t•& hold harmless the City of La Ouinta, its officers, agents and employees.
4
.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 represgntatives of this City to enter upon
the above-mentioned property forInspection purposes.
^` Signature (Owner/Agent) `
1�P�i9+ ., PERMIT
BUILDINGPERMIT�`-
DATEf"� v r ii tl, .VALUATION Fri:-: �?�v LOT rr .'sF t . TRACTIPAaw 7.i�.ts4
J A L
tl
Yx
JOB SITE m. s, r t :' > < 4 ,b(�tu b 3rK +}9 Y
ADDRESaf''��:5"FC)+"t
APN
�.. �+, .'�tk='r ;r,;r.:. ..):3},�., ;;�.;,�•� �SJr•,t't>� rr;;l� .�,i,�.
s.r�l. ;'` ' �A «r �s;o
OWNER . i&'�} E •, I% * .i:: Y r t �Yyu
i," •};'>,4 t.. ? 'i q"�G. .� Y ;.,5ct`:.k
CONTRACTOR /DESIGNER / EN (NEER i x`;r), Y`.
1'.,�R„rt �.,,'��"'n4.f"%4%
PCiA' Sl' R 7I : Ho z.); "':
i CON&tR,UC1'ION; INC
42.600 6. Afl(�iYNR`i COURT ,•
.:7062 CONVOY COURT"
kt
PAi.AdDEMX' ` CA' 922:11,
BAN DIWO CA' 92111-
USE OF PERMIT i
GP..N1?R.AL F3'U1Ii/]N(3
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f31.1)UfS -33.381;.55»393, S5401 REPAIR HANDRAILS &DECK
COATINU
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N , VAi.LIATION 4500.001,5
i
rESTIMATED Carr of oommvmon
-
4vsw.00
PRRN r FEZ 9113AU"IM
CONSTRUC3 ION VEE )01.000-418.000 $30.00
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I
•, ti MUS..'' ON` AND MAR �
, I " i L103 PRE; -PAM 14=1
$30.00
SO
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733
i=4't2 TA1G i'ERl]'C ll�l§i A3U NOW21
$30.00
RECEIPT
DATE /
BY
DATE FINALED
INSPECTOR
Date