0103-082 (BLCK)NSED CONTRACTOR DECLARATION
I hereby affirm undeP"�32ifdlt�li3T�S7jUT�TPfarT'dPFilfG�tf�fn7tsT6PT5"tYT
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
717 0,11,
0 R_, . 131/2(
,
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).
( ) 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.
( ) I have and will maintain workers' compensation insurance, as required by
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:
Carrier Policy No.
JTATE ('010 DJ33 FU i i�:.457-00
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) 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' compensatio prov' ons of Section 3700 of the Labor
Code,s II rthwith comply with se s.
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 in 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 tVe;7on
the above-mentioned propert o Ins ction purposes.
Signature (Owner/Agent) Date
DATE VALUATION
10,s 1 9,00
LOT 0103-081 TRACT
JOB SITE SC;J - //S- APN
ADDRESS
1_tn VIA URV'.Ct:� - -
OWNER EJ
/ �, 7 / -7 6 CONTRACTOR / DESIGNER / EN (NEER
NOttT'HCH-.1EST- SOD HVRE TDEVELOF'MEI�TNOR'11PNEST-SOIJ1` BATESl-DEVEL.C'MuM.r
17.5 64 A ['OTJ;•1'1 ,Y r L{ -TE'. DR 77-: �t A r'OL ri'iT:`Y" CL* TB DR
YIALi11 DESERT CA. 9221 1 PA 1/1 DESEPT CA 92211
X7601408 3195 CDD-ff 6133
USE OF PERMIT
141:.' LP' d 5' C_]APDEIN WALL • CITY STIP A14DnRD • FOR1 I,OTSO 169 -1 o
VIA 01iME.T0. 11NR18" TIc3.A.TI0N FEE /CHA,RCIED FOR 63iORK WITFIOUT
PERMIT.
3 FT, WALL
1,112.00 LF
"F_ST1tN1A1ED COST Ola' CO.1,' R.LCnO.IN
PERIVLTT FEE SIRMA4JALRY
C'DWSTRUC'TION FEE 101.0100.418-000
11,0IES,Ti0ATIO14 FEE 101-000-423-000 $141.00
STlY-TOTAL COLdS'[Tl'UCI10O 4' A.DrD P.-L?tv CHECK
LE» PRE -PAID F EE3
T'OMNL PE_MN= FEES DUE NOW
RECEIPT I DATE � 1q /Ot I'Ve. I DATE FINALED I INSPECTOR
30,56930
$582.00
$0.00
$582:00