0212-137 (MISC)LIULNSED CONTRACTUR DECLARATION
1 1 P'l
eidury! a-1 am
BltjL�6fp 'N'
under -provisions of. q
I hereby i4im uriiler pen t �-licensed
Chapter 9 (commencing with tiiction,7000) of Division 3 of the Business and'7:
i ".� .
Professionals Code, and my LicenseisInJull foice'and effect.
License # U Exp Date.
c. Class ,,
0249/2(
7-74362
T: A.
Date ,
Signature 'f Contr r,",
j
OWNER -BUILD DECLA
I hereby affirm undg.r penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
1, as owner of the property, or my employees with wages as"the'ir sole
compensatlori ,will do the work, and the structure is not Intended orofferedfor
sale (Sec. 7044, Business & Professionals Code).
1it as-. owner `of the property, am,exclusively contracting; with licensed
contractors to construct the, project "(Sec. 7044,,Business & Professionals
Codex.
'I amsx`e'6pt Under"Section B&P.C.'for this reason'
Date
Signature of Owner,, -
,J'. 1, WORKER'S COMPENSATION DECLARATION
i�Ii;'erebjaffirm u-nder'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. A . . . ,
I have and will maintain workers' compensation -insurance, as required by
,f;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:
Cartier STATE RAID Policy No. 468784
(This section reed' not be completed if the permit valuation is for $100.00 or less).
�1,,, ( ) I certify that in the perforrhance 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 provisions -q Section 3700 of the Labor
Code, I shallforlhwith
<)complywith th'Trcv
isos.
696_f- ,Applicantbat.:
Warning: Failure to secure Workers" 6mpensatl6wcoverage 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 attorney's fees.
IMPORTANT Application Is hereby made to the Director of Building and Safety
fore a permit subject Jo• the conditions. and restrictions set forth on his
application.
t.4-11. 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 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 ISO days from date of Issuance of such
I permit, or cessation of work for 180 days will subject permit to cancellation.
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 duthorize,repreientatives of this City to enter upon
above-mentio red property to I speption purposes.
Signature (Own6r'/A'gent
A PERMIT#
44 1",_ 11'
�VBUILDINGIPERMIT
.� .fix
DATE0I VALUATION fAk,* u, LOT,', -0,
0 tv 0*v i, i
14 ,•,
: � l "
JOB SITE
ADDRESS.q BUM. 4 VMGRD FOMI,�
APN
Tc. N
lvv%
u
OWNER CONTRACTOR/DESIGNER/EN INEER y
4.= 41_
P" VMff REMM41=1 BOA" tEPOMCOMMUC710H
42-6W CAROLINE COURT. 7062 CONVOY COURT
PALUDIMT, CA 92211 SAN DIEGO CA 92111.
A(Sst3�SG0-Q p6 CBI,0
USE OF PERMIT
BLD0. 41t,534121,iS.43?, 5SA45, RMV11 HANDRAILS DECK
COATiN6
VALUATION 41."0100 LIS
EMMATIRD COST OF COVYFRU MON
PkIZMff M 9UMMARY
CONSTRUCTION FEE 101.000-418.0,00 $30.00
err
9MUCIION AND PLAN CIMCK.
$30.00
PRE-PAMMM
$0.00
LIESS
W4 rl W
AL PKRM"FWDU) NO'
k',' 21 2
00,0D
611 Q
T
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L.R
RECEIPT
DATE
BY
DATE FINALED
INSPECTO