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0212-135 (MISC)=?us d.,', t = +nrvrr>t r LICENSED CONTRACTOR OECLAFiAIION...V,;, ,.-„,,,-,j,.A NtHMIi e� _Y a ynr� �. .. DIN =:PERMIT rt a .� := "he perJury:tFrat l aim Iicensed'untlerprovfsions of� � BUI�, G x y N •s. ..v va«i'! . a:. 9ixE.4'. s,, i 'k. ,..,,_. •,a3"•y w•... ,'�,_; 1—, Chapter 9 commencing with,.Sectlon`7000j'of Division�3_of the Business'and .,_. onTE w L.r,F,vALUAnori `+ . ' ^°� *,i..LOT• Jr, P ( ia. .. i•2a:. t , _ N Professionals Code, and my License”. in'.full:force.and effect �: r,.'ffyIS ;;5 * •., + ,'� , j, x �Aly . �j �► ' ' `�''�3 = r ;y' ' ' t:^" �.. W t 7• b3: a, �. r, r,y f.. ^� *'- .r`i'g 2 •'':r<'Se.. t .. License rYrt°'' y 1 s F `;g n ``rid Lc: class , x �+t tExp :Date �' ,r .� M s<- .. s• ' ,.< r •c•�i"+ ,a --v ' �a+r • •+.JOB + l . - c..f.. t�»� t r., "". ' 1., w •., APN �•, �}: T. s "4JF�. p i �{ I, /y 1nq .rr� JOBS 'e• F V- .l$ a`k ;r.t. SRaC •...0 .'i ay t• 1� �' k'e`. ADDRESS.,„ ;E�yFVVJ.; d'✓'(/ I';.� t'!a.;u ,�e'+�, k: #... -,.f Y . + - ati. o" ria3 t `,�aa==y: 3 eL1`� "fiat. s, g..c rf- T. . S aFd• v F '.r 4 "'. a: G w, , y �...t OWNER', CONTRACTOR or 11 Z rZDate G' Z� Signature of Contractor t` CD .O. 1- ,.•r.:t?4A.,-1-. .� t.....!., `x �.,r.' •t.fe. a: .as.':, 'r '}.i; # ; ,!., ''OWNER -BUILDER xD1:C RATION �. �" - PGA RE8ft)M0% Y HOA,'•` WL" - .7 0 L� ... ,','�J:, i�... t' , .. � a boOcA�c sCotnl r ,,;f', �tJdaC4N�tOYCom ), [L ~ I hereby affirm under penalty of peryury that I arra exempt from the Contractors , •. License Law for the following reason: , PAI,Z►�DEST t A ,92211. ;SA&�TUIECi4 CA = ��� �.� I, as owner of the roe or m em to ees with wa es as their sole 4 {85816f�•pb98 G'"�L# Y r r ::"compensatio`n `will do the work, and the structure is not intended or offered for j f sale (Sec 7044;` Business'& Professionals'Code):_ t 't' , « y n 5 USE OF PERMIT j - ,. I ..I, 66%owner of. the' property;; am exclusively, contracting• with' licensed z ` i.contractdrs•to construct, the project (Sec.Y 7044. Business &`:Professionals "� .,''•1 d< iitxl►. 7:1381 89.593" 5S-6©3. R<rPAlit HAt�DRAtI.S �.P.CCIC • ' ch", ..�O tram exempt under. Section r B&P.C. for this: reason :f r e Date t, s: Signature of Owner ` , �� >>: laOAlAit>I -' is U Q f� }' `:WORKER'S COMPENSATION DECLARATION. ++' Q3/'. r ihereby,afflrm under penalty of'pe`rjury one of the. following *declarations: K Y 1 have and'wlll maintaln•a certificate of consent to self -Insure for workers': ' VALUATION 4,00.,00 LS H 0"'i _ (• );, `' compensation, as provided for' by Section 3700 of the Labor Code; °for the l --performance of the work for which this permit is issued a I have and will maintain workers':oompensation ' insurance, as required by ', ` , 0, - JSection 3700 of the Labor Code; for the performance of the work for which this Q i r d' f,: permit is Issued. My workers', compensation'insuranoe carver &'poliry no: are:. I t , i Policy No. V I �wr arAr� _ : 4ae" Qy����Q�[jy ���;�/�/�:p�YED Corr OF COl�s�a C170H 4.55 00 .^ i.Rl,i�dY.iJ4 F". OV1q�R" A— (This`sectlon'need•"not be'completed if the permit'valuation-Is for $100.00 or less) CONSi`RUCTIpt� 3S 101 •1t00.41$•tJ04 MOD ' I certlfy that In performance of the work for which this permit Is Issued,. ,j I shall not employ'any person. In any manner so as to become subject to the ( - ff i✓,l tis workers' compensation)aws of California,�and agree that if I should become '. x� subject to the, workers' compensation pr visions f Section 3700 of the Labor i 3 ��`' , de, I shall forthwith comply with those Orovi ns I( ate:: ,' e"'�`A Applicant Warning: Failure to'secure Workersr` ompensation coverage.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. • -.' s • ,IMPORTANT Application is hereby made to the birector.of Buiiding'and Safety I •: ;, for a' permit` subject, to - the conditions and restrictions set forth on his applicatlon. U QUZY 1. Each person upon whose behalf this applicatlon•is made &each person at � � N � AND r Com' V'.IO•00 jar whose, request and for whose benefit work is performed under or pursuant to IMS ?. {„ 00 any permit Issued as a result of this applicaton agrees to, & shall, Indemnify QJJJ%'TA Pit�•Pl� D s.9 p' t .& hold harmless .the Clty of La Quanta, Its officers, agents and employees. C1T`f *fir CEPT 2. Any permit Issued as a result of this application becomes null and void if pttJANCE d1L F, T MS DUE NNW AO 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. ` ? Tcerti fy 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 4 construction, and hereby authorize representatives of this City to enter upon •• ' the above-mentioned property f9r-It�sppction purposes. ' RECEIPT DATE B DATE FINALED INSPECTOR e,, Signature (Owner/Agent)f �� Z "� ' �f Date �;�"�f''�ta�'' 1 7 �1