05-0003 (BLCK)P.O. Box 1504
78-495 CALLS TAMPICD
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
Application Number: 05-000-3
Applicant:
mppncanrs maning Address:
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: /'3.05
Architect or Engineer
jvcnnect or tngmeer's Address:
Lic. No..
BUILDING PERMIT DECLARATIONS
LICENSED CONTRACTOR'S DECLARATION
I hereb rrn under enalty of perjury that 1 am licensed under p 'sions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals
C , and my Lice se in full force and effect.
tenselass icense No.
Vire rector
aL/ q
if OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permll to file a signed
statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business
and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violationof section 7031.5 by any applicant for pem* subjects
the applicant to a civil penalty of not more than five hundred dollars ($500).):
U 1, 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 and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does the work
himself or herself or through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for. .
U I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec, 7044, Business and Professions Code: The Contractors* purpose of sale
State License Law does not apply an owner of properly who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
the Contractors' State License Law..)) .
U I am exempt under Sec. , BA P.C. for this reason
Date Owner
WORKERS' 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.
and will in ' workers' compensation insure ce, as uire by Section 3700 of the Labor Code, for the performance of the work for which this permit is
ss d. My ers' comp sation insurance cam d b9f are.f
Carrier Policy Number C�
_ I c ' y at, in th performance of work for which this permit is issued, I shall not emp oy any person in any manner so as to become subject
compensation laws of California, d ag ee that, ' sho d become subject to the workers' Com to Ow �,
fort 'th comply with those pro ' ' ns. pensation provisions of Section 3700 of the Labor code, I shall
Date Applicant
WARNIN : FAIL RE TO SECURE WORKERS' COMPENSATION COVERAGE S UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($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.
I hereby affirm under penaltyof CONSTRUCTION LENDING AGENCY
perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lenders Name LAC-
APPLICANT
Lenders Address
IMPORTANT Application is hereby made to the Director of Buildin SaAPermit CKNOWLEDGEMENT
1. Each person upon whose behalf this application is made. each person at whose request and for whose benefit work s Porto to the conditions and restrictions set formed under or application.orth on this ursuant to any permit
issued as a result of this application, the owner, and the applicant, each agrees to, and shall, defend, indemnity and hold harmless the City of ,
officers, agents and employees for any actor omission related to the work being performed under or following issuance of this permit. Le Quintsits
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 canceWation.
I certify that I have read this application and state that the above into ti is correctM I gree to comply with all city and county ordinances and state laws relating to buUdN'
constructio a hereby authorize representatives of this
ntioned property for inspection purposes.
ate Signature (Applicant or Agent):
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