0105-103 (RR)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class _ Exp. Date
62.5035 + ^39 OS,r? 11)
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: '
( ) I, 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 & Professionals Code).
( ) I, as 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 B&P.C. for this reason
Date ' Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under 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.
Lhaye and will maintain workers' compensation in§urance, as required by
(Section 3700 of the Labor Code, for the performance of ttie work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Cartier `� _` F r PolicyNO.` ( C
K !"moi l4 19 L-' ...- - 28- 0 j t• t 6 8
(This section need not be completed if the permit valuation is for $100.00 or less).
O 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
workers'• compensation laws of California, and agree .that if I'should become
subject to the workers, compensation provisions of Section 3700 of the Labor "
Code, I shall forthwith comply with those provisions:
Date: Applicant "
Warning: Failure to secure Workers' Compensation 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 Section 3706
of the Labor Code, interest and attorney'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.
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, indemnify
& 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 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 representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Date
BUILDING PERMIT PERMIT #
DATE VALUATION LOT 0.105-t_03 TRACT
X J $4,2.50,00
JOB SITE
APN
ADDRESS'D71-LSi�
j-fi I.i�45 T�7rKid3lr l_s f.l t1 -LS E�.�.ud:.T31"
OWNER
CONTRACTOR / DESIGNER / EN (NEER
GAGODlAVAPL'
CUSTOM RQORI_�G CO.
49-03;/0451t.'RS MTGT(?NSTF,.EET
38-980 RAI-4CHO L400 COYOTES
LA QL1L1'TA Ll-A'i t'7 �}C3
-
L}'vTDTC) CA 9,'2203
(_760)345-3751. 1? r
USE OF PERMIT
GEI1 HRAL ]~1MLDli� O
BUILT LIP RE-ROOIF CLASS f
REROOF 4,2510,00 J
s
. , ". _• EST1MTAT= COST ORCOIliSTIRUC`1G.[V '° .:
r4 50 00
-PEP,A4t—T FEE 9'U_ iARY ?'
1fji-0n0>,1 000 €3ti,;r(I
`13,
SL;P-TOTAL, COQ 151ti L TO,r'iON A14D P Ati C -HECK
$30.00
LESS PRE -PAID FEES
TOTAT, j' t T-,1 FErs lay?E'I�TOI'�r
0.00
RECEIPT
BY
DATE FINALED
INSPECTOR