0212-136 (MISC)_O :) M
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LICENSED CONTRACTOR -DECLARATION
1 hereby affirm`urider penal ty„oi perjury.that I'am licensed under provisions of 9,,
hapter 9 (commencing with, Section 17000).,6f Division 3 of the, Business and
Professionals Code, and my License'is in full force and effect. 0 � . -,. N_”
License # i , ,' sr" Llc: Class R Exp. Date
rateSignature of Contractor 'R
t F OWNER -BUILDER, DfCLARAiI6N'
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I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
(w) I; as owner of the property, or my erripioyees with wages ras their sole
compensation, will do the work, and the structure is not Intended or offered for
sale (Sec. 7044, Business & Professionals Code).
• 1 ), I, 'as powner of the property, am exclusivelycontracting with, licensed
contractors, to construct the project (Sec. 7044, Business & • Professionals -
' Code). , r
S'O I am exempt under Section ` 4 B&RC. for this reason
Date,f Signature of Owner
t", 74-4-4i., WORKER -S COMPENSATION DECLARATION , •:. ;
' A `,hereby affirm under penalty, of perjury, one of the following declarations:
have and will maintain a certificate of consent to self -insure for workers'
.I,compensation; as provided for, by Section 3700 of the Labor Code, for the
h, performance of the work for which this permit is Issued. `
( I' have and will maintain workers' compensation insurance, as required by
4 Son 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; ;Polic No.
# 9TATR FUND' s Y 4fi87ff4
54,
.(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
...subject to the workers' compensation provision• of Section 3700 of the Labor ;
Ce, I shall forthwith comply witlj•th e, prov' ons.
ate, ?f—;,� rT Applicant � =' ',
`Warning: Failureloo secure. Workers' Compensatio rage is nlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in .
addition to the cost of compensation, damages as provided for in Section 3706
t.of the Labor Code, interest and attorney's fees. _
IMPORTANT 'Application].s hereby made to the Director of Building and Safety
' for a permit subject ! to the conditions and restrictions set , forth on his
.,,application. '
Each person upon whose behalf this application is made & each person at 'I
whose request and for whose benefit work is performed under or pursuant to
any permit Issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Ouinta, its officers, agents and employees.
.2. Any permit issued as a result of this application becomes null and void if
' work Is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information' is
`correct. I agree to comply with all City, and State .laws relating to the building
construction, and hereby authorize represent�tives of this City to enter. upon
the hove mentioned property fgF-irisVpurposes
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�' ignature (Owner/Agent) -�!= Date �� t rs �;
: r BUILDING=PERMIT-i",MR
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DATE a.} & Y - %' .vALUATION
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ADDRESS ,y''; W.Wa «9 VYII'�41$D our `, Jr" J`, : 5DI . �`r ;,��.. , , - r
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CONTRACTOR'/ DESIGNER/ ENGINEER
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PCiA'WiFSTRWIIDP'NdZAI.HOA
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1"POM Coormucuom, W. C
42-600 CAROLM COURT
7062 CONVOY CO.UUIRT = �{
PALM DJJ=T CAS 92211
BA14 DIEGO CA' -92111'
(858)560-0698 ' CDIA
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USE OF PERMIT
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fiLM.9 .Pl•504 15.513, 53-51;5. RZPA)K HMDRAILS & DECK
COATING
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VALUATION 4,500.00 LS
MTR+iAIM) COU, OF COlV5'MiJM1014
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PEF&ffr FTA 6111h AIRY
CONSTRUCTION FEE 101 -0100 -418 -Wo 110100
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RECEIPT
DATE/
1 d. �/
DATE FINALED
INSPECTOR