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9708-042 (AR)rn 04 G9'• Oft^) 1�_dU-) W 6Zr� to 0 JV� Wa U) Z co LO N ON 0 °) d Q cc Q 0 LL X W — mUU O d � H Z w5 Q J LICENSED CONTRACTOR DECLARATION I hereby affirm undegpenalty 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 ,r Exp. Date Date�'�� " Signature of Contractor r OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury thattI 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. (Th' , s8kcfion 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 becomer subject to the workers' compensation laws of Californiarand agree that if l'should become subject to the workers' compensation provis onsof Section;3700 of the Labor Code, I shall forthwith comply with those.pf•ovisidns.J ,+ Date:. '/ r°Ic:Applicant Warning: Failure to secure Work ers�Compensation coverage is unlawfulxand 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 SectioA 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,mspection pluurrposes. l Signature (Owne"r/Agent) — ff Date • PERMIT CONTROL# BUILDING PERMIT `"{'.'"� 5.71-3 DATE R/ 4M7 VALUATION S2.949-50 LOT TRACT �. JOB SITE;S(i-tZ:S APN , ADDRESS OWNER CONTRACTOR/DESIGNER/ENGINEER pit usota ^;utt,:�t�ti ;(i!2.5 ORAND TPUWERS LA. t21.�'Tr� rA CA '47253 CBT,# � USE OF PERMIT MAN f s t'* r.lt.ti s1t11�1'.l`tCrtV �}rtf{r�t��t; Ni2i t�. tirvr�a7 S"i��i' Sk`i:lW NGJIiCV LS,.04,0 Nt:Y1,1ci31.i:Tujk,o T+) Cc)NST_k TC`}'I(:JN W(jKKFR ("'RANK FOR NO Pw.RXII t' r�JTt y�r�,}l?� E�YT(4rt�+l�.t4lI:l3 t'iN ,'xr'r'fi I�RANilf4t� f:`(:�4fl�I,r: j"F', F;},}:tJ'T'i2tt:A1. C*08 e' Qri i:O !ff11 :t:A:'.10NN Pl RMI T .Pi.V.SOWn'lAR ..c P(,AN t'f•tla'/:'%; FW, �."L?nf,;"1 fit rf"Ct4 )7�t l bir 1(?!-lltlf) ail fi-(itln 1%4.00 8711(ONO M(YVION Phi: - }llitit:) tOl-f}tlti-241-0M $ Et MT,X 11(1, A'FION UWE IQ l -f )0-423- N►f•) 3�g..33 � cn LESS !'lel;-PAID RTS, $().f}Q '!i'O`l'AL !'l+ RN1?'f N 14' N 00F, NOW �'2QSti.f i> RECEIPT DATE BY DATE FINALED INSPECTOR 4t L_� INSPECTION RECORD ° OPERATION DATE INSPECTOR OPERATION DATE TINSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air ^tee!-•• Combustion Air Roof Deck Exhaust Fans O.K. to Wrap F.A.U. Framing -2 V. Compressor Insulation _ Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath - Final Final BLOCKWALL APPROVALS POOLS - SPAS Steel Set Backs .Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Pibg. Test Final Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans, OX for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Encapsulation Gas Piping Gas Test Appliances Final Final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final ` 'Utility Notice (Perm) COMMENTS: June 1,1998 Nelson Berkowitz 50-125 Grand Traverse La Quinta, CA., 92253 RE: Addition Permit #9708-042 Dear Berkowitz The purpose of this letter is to inform you that your office addition , for the project at 50-125 Grand Traverse, has expired. In accordance with 1994 UBC section 106.4.4, no further work may be performed until a new permit has been issued. Please contact Kirk L Kirkland, Senior Building Inspector, at (760) 777-7012 to obtain any information you need regarding a new permit and/or any required inspections. Should you choose not to complete the project, we would then have to pursue any or all of the following actions: 1) Abatement of the project through the City Attorney's Office and Code Compliance Division. 2) Notice of non -conforming structure placed upon property profile. 3) Action filed with Contractor State License Board. Optional if Owner/Builder. Please contact us at your earliest convenience prior to 10 working days to resolve this issue, and for any questions you may have. Sincerely, Mark Harold Building & Safety Manager Kirk L. Kirkland Senior Building Inspector cc: file A CONTRACTOR- OWNER - CITY OF LA QUINTA SUB -LIST ADDRESS JOB ADDRESS �o �1Z.5-✓��ir/� It is the responsibility of the General Contractor or the Owner/Builder to monitor the sub -contractors that are on this list are the same persons performing the work. Any changes to this list must be approved the City of La Quinta Department of Building & Safety prior to work being performed by a changed sub- contractor. Failure to comply will result in a stoppage of work and/or the voidance of building permit. . ::>::;::::>::;:.::::>::::>::::>:::: >::>::>::>:.>;:.:::: . ;:.:::::>:. .... :>:::::c:>:::; CITY ........ ::::<:::::::::::::>:::.>:>::<::::>::::>::::>::::>::::>::::>. :::........:::::::.::::::::::::::::::::::..::.:::.::::.::..:.::.:.::::...:..::.::..::::.:.::::::::.::,T,Y.PE;;O.F.::::::.......................................................... S.U6:=CONTRA ...:::. .;:. S:TATE..................................W ... .. ,.>. .............. R . D ::::<.;::::::: T.. A . E...............:::::::::::::::::::::..:....................................::.:::.:.:.::.;:.::::.::;:;:::.::....:::....:...:.............................::................................................................................ NAME::>::: .:...........:...::::::::::::::::::::::::::::............... . .::.. . CO.NTRACTO.R:::S;;:.;:.>;::::::C. .......O INUMBER>>><>>€> . < MP.; NAMED>::::>::::>:::<:>:: <::LI..CENSE;::;;;;>::>:<:»::::>::>: . C NSE><>>>>><>NU.IVIBER<`<'>:.:;.<.:<.;:.: ; :.:;.:.;:.;;::;;;:.;:.;:.;:;:, ...... EXP... DATE ..........................................: ............................................... .............................................. A C-12 / .......................................... EXCAVATE>><>> .............................................. ::'PIP .............................................. ............................................... .............................................. ............................................. C-34 C-34 ............................................... :CO:N:CRETE/ <>'' ` -X : C-8 FOU,NDATIO;NS::::;:; ASPHALT «>< : ............................................. A FRAM IN ><> '>> »>> G - S �i�p:._ -51 STRUCTURAL::::::;:;::::;:::; MAS.O.NRY>>»>><- C-29 LA .....:................::::::::: C 36 , HVAC<<"'<'` `'```` A&e,4a� Z C-20 v 3 ELECTRICAL:::;;"< C-10 , (General]> <..... ;ROOFING:::::::»<>«' C-39 SHEET METAL::::::;;;::::> C-43 C. C. C L`/ C-1 592 7 , `.GLA:S'S% > < <> <- C-17 LAZING::: G <><':< INSULATI,QN .;� : C-2lbd SEWAGE'DIS:P: C-42 'PAIWING% «'< ?< :::: C-33 ;:.DECORATING::::::;;::::! ABINETS%':><`>»'> C-6 INSTALLATION»<- ;FENCING :f . >: >` `> C-13 LANDSCAPING;::::;::':; C-27 PO:pLS:><::>:> ...................................... C-53 OWNER/BUILDER INFORMATION Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified. For your protection you should be aware that as "Owner/ Builder" you are the responsible party of record on such a permit. Building permits are not required to be signed by property owners unless they are personally performing their own work. If your work is being performed by someone other than yourself, you may protect yourself from possible liability if that person applies for the proper permit in his or her name. Contractors are required- by law to be licensed and bonded by the State of California and to have a business license from the City or County. They are also required by law to put their license number on all permits for which they apply. If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be aware of the following information for your benefit and protection: If you employ or otherwise engage any persons other than your immediate family, and the work (including materials and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or subcontractors, then you may be an employer. If you are an employer, you must register with the State and Federal Government as an employer -and you are subject to several obligations including State and Federal income tax withholding, federal social security taxes, worker's compensation insurance, disability insurance costs and unemployment compensation contributions. There -may be financial risks for -you if you do not carry out these obligations; and"theseiisk§'ate especially serious -with respect to worker's compensation insurance. + For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if youlvish, the U•..S. Small Business Adminstration). For more specific information about your obligations under State Law, contact the Department of Benefit Payments and the Division of Industrial Accidents. If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their work personally or through their own employees, without a licensed contractor or subcontractor, only under limited conditions. A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/ Builder" building permit, erroneously implying that the property owner is providing his or her own labor and material personally. Building permits are not required to be signed by property owners unless they are performing their own work personally. Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your community or at 1020 N. Street, Sacramento, California 95814. Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of these matters. The building permit will not be issued until the verification is returned. Very truly yours, CITY OF LA QUINTA DEPT. OF BUILDING AND SAFETY 78-495 Calle Tampico La Quinta, CA 92253 (760) 777-7012 FAX A60) ,777-7�1TT1 1/11 ln.i O R'S SIG RE/DATE 8 -/ZS ��z2 PROPERTY ADDRESS G1-7 0 ?- 0�1� PERMIT NUMBER(s) Sao L�f—T11�S1�G ALL � � w I ,� P iii .. •. .%.` -�� S�Ya-. "VmFETY DEPARTMENT TALL u'�vaaEr�!it7E. F�i' ��------------------------------ AND ALL APPLICAE C)C oar 1 St mWildwy - sa"Izrday` slf ny;3y. _ I ay . 1&*dy Satuxdj&y Sunday W. :------------------ - c��-:�-------:�. err►.: _::-:::---------------------------------------- =v_: F: :;= ----------------------------------------- ate -: -}----- --------------------- ------------------------------------------------ - ---------------:::y :::--:-:_ �:: ------ -- ----------------------- - Ac ---------------------------- ---------- --------------------------- --------------------------------------- ---------------------------------------- --------------------------------------- -------------------------------------- --------------------------------------- --------------------------------------- ........................................ --------------------------------------- ........................................ --------------------------------------- --------------------------------------- ....................................... --------------------------------------- --------------------------------------- --------------------------------------- --------------------------------------- --------------------------------------- --------------------------------------- --------------------------------------- --------------------------------------- --------------------------------------- - -------------------------------------- --------------------------------------- --•------------------------------------ ---------------------------------------- ---------------------------------------- --------------------------------------- --------------------------------------- ---------------------------------------- L:.!:::::::::::m --_ Job Address: 50-125 Grand Traversel La Quinta, CA North =--Om- Grand --► Grand Traverse Dr. & Mrs. Berkowitz Office Quarters Al D. None Job No. 9715 ----------------------- --------------------------------- - - -` ' - ----------------------------- -=_-- �` --------------------------------------- --------------------------------------- --------------------------------------- --------------------------------------- --------------------------------------- --------------------------------------- --------------------------------------- --------------------------------------- --------------------------------------- 0. --------------------------------------- --------------------------------------- ---------------------------------------- --------------------------------------- --------------------------------------- -------------------------------------- --------------------------------------- --------------------------------------- -------------------------------------- --------------------------------------- -------------------------------------- -------------------------------------- --------------------------------------- -------------------------------------- --------------------------------------- --------------------------------------. --------------------------------------- ---------0----------------------------. --------------------------------------- --------------------------------------- --------------------------------------- ---------- ---- ---- - -------------------------- - ----- ----- .--------------------------------------- --------------------------------------- --------------------------------------- --------------------------------------- ----------------------------- ----- ----. --------------------------------------- ------------------------------------ ----------------------------------- -------------------- ic-:A r iai--------:: ---------------------------------- National Design Corp Thru the wall Heat & Lao 3.'.0" Composite Exterior.Door with weatherstripping & threshold Job Built-in desk X_ MICI te) Approximate Dimension 7'7"x 704" Exterior Walls Existl A 41 ilt-in dercounter :rigerator . th formica p (white) -ior Wall WCDF )C W/ R-13 ation 'Type X witw LroCK Garage side General Construction Notes! Windows are dual pane a4texigtin 9 Wallboard to be 5/8" TypeX Throughout RC Channel 16 O.C. 9 ceiling Provide Telephone & T.V. outlets Provide Electrically con nect6d,battery,__ backup smoke detector I t Insulation- R-30 ceiling, R-1 walls Y This addition has 3 existing exterior walls with styrofoam & stucco. We are adding an entry door, one interior wall in the garage, and air handler. Dr. & Mrs. Berkowitz Office Quarters Drawn By AID. Scale None Job No. 9715 National Design Corp JOB: 50-125 Grand Traverse . La Ck*d.-L CA 92253 AL DURRETT P- 0- Fkm 3371 Palm DeseM CA 92261 7W-%0-7955 760-360-6= Fax liceime Na. B-451035 LOAD CALCUIATION Wei z I I X"" GENERAL L[CHTINQSQ-Fr SWatls X 2230S4FL lum 2 APPLIANCE CIRCUITS 4)M LAUNDRY CIRCUIT 2,400 DRYER RANGE OVENS 7;M COOK TOP 9fim TRASH COMPACIUR DISH WASHER 7,400 DISPOASAJL 2,400 MICROWAVE 2,400 EXTRA KNOWN CIRCUITS OlIke Addition 5 Watts X go Sq- FL 400 Air Handler - 3.= joilgoa V TOTAL L[CMMG MAD FIRST 111K AT 100% REMAINDER AT40% A/C 6 TOM 20M FERTON TOTAL LOAD 39.940 TOTAL LOAD 240 VOLTS = 17,9M 39.940 D AjEZ,23LV�� BY ' riricaze of Compliance: Residential ipace ) 0! '�) CF -1 R oH?Ft �ftta Date olact Add as �� BwtCtnq Perms[ r: 1 Plar CnecK r Date xumer►tation Author �Telepimne _ �S Field Check i Cate om0�1 ant a "thud (Pactuge. Pont System or Computer) Climate Zone Entomement Agency use CNY 3ENERAL INFORMATION 'otal Conditioned f=loor Area: ,40 tt2 :wilding Type: Single Family :hoot one or more! Multi -Family :vont Orientation: North / East / South 1 Wes (Input orientation in degrees and vumber of Dwelling Units: :Ivor Construction Type: �SlRaised Floor (circle BUILDING SHELL INSULATION Construction component insulation Assembly Locatiory F yoe R -Value U -Value (attic. to a. watt .............. A -/- wall .............. X Floor....... Floor....... Slab Edg( isting-Plus,Addiiiort t.. r " ,' ~ t\.A All Orientations �n. zE': TY ds 4)11, t a or both) ti �-c�a 14 - FENESTRATION FENESTRATION Shading Devices Y Fenestration Area Fenestration Interior Exterior Overhang Framing Type Orientation (Sf) U -Value (faller blind, etc.) (shadtltttcreen, etc.) Nownci) (metaimoodNinl) Front..... ( ) Front..... Lei....... (v) /2 _,�,� _ _ .�oo/J� Lett....... ( ) ---- Rear..... { ) Rear ..... ( )' Right,.... (1-) /�i — 1175 A//- ;FT - - -- woo.0 Right..... ( Skylight ....... Skylight ....... THERMAL MASS Type/Covering Area Thickness (slab/aX osed. tile, etc.) (sfI (inches) 00 SD Rsrirq January t gin " . " 1 Ju1_28_97 01:14P City of La Quinta 760 777 7011 Certificate of Compliance: Residential (Page 2 of 2) CF -1 R HVAC SYSTEMS roto: input nyarornc or camawsd rrya+arrc am unser Water Hoawq Systems. except Desgn Heaarg Load. Distribution Heating Equipment Minimum Type and Ouct or Type tturnace, heat Efficiency Location Piping Thermostat oUMD. stc.t (AFUE/HSPFI 1dUCT satin. etc.) R -Value Tvoe t . For smart pas slots" (rated input S 75,000 For large pas aterage water Maters t rated For Mlstantonemn gas wow-hestiera, test F SPECIAL FEATURES/REMARKS in S stem Cr Stu/hr) (aftons) Efflcie ° PrART1 Et' [1)," rsatsUirtoe'aiwid'fi w pw v wow�. list Energy FWW, 0j". list Rated Input Fiwaovs�y•�fltew%q'_and Standby Loss. dtt�r Ef}fes.r+ejr.`'HUCTVOIN a sheets it necessary COMPLIANCE STATEMENT IA!`,D A[_L A CODECS t'is carmicate of comptanax lists me btAding lin and pertormance spetiticatlons nested t mpry wttn Title 24. Parts t and 6 a the Califama Corse of Reguattons, and tris ulattons inotvilw uteri overall design resu=Wsthrlity. Wttest is subattttted for a ongle budding plan to be Ut 0 multiple oriennaons, any shading teattue mat is varied is txkam to tits Special FeatureslRemams section. esigner r oyJrn (pw surer»" a Prokussww c"o) Documenta�thor rvaTe: ,.,�C� 7 Norm: TttlarFirrtt: IP4 ✓: /� TIWFirm: Adtlsss: 8 /�%¢/� yi-✓E� ldftss: %— S �---v 7,tl C Z7 rs►apnone: _ -/1- - 7 tdar) Enforcement Agency Nerr9s: rat,: Tewo m: _ 77j/_ - (owl, Cooling Equipment Minimum ouct Type fair Conditioner, Efficiency Location oust Thermostat Configuration most ourno. evac. cootina rSEER) anis, etc.I A -Value Type (said or cacxage) WATER HEATING SYS ;�� Energy Extemat Hated Tar* Factor or Tar* Water Heater OistriWion Number lnpA (kW Capacity Recovery Standby' InsulaWn t . For smart pas slots" (rated input S 75,000 For large pas aterage water Maters t rated For Mlstantonemn gas wow-hestiera, test F SPECIAL FEATURES/REMARKS in S stem Cr Stu/hr) (aftons) Efflcie ° PrART1 Et' [1)," rsatsUirtoe'aiwid'fi w pw v wow�. list Energy FWW, 0j". list Rated Input Fiwaovs�y•�fltew%q'_and Standby Loss. dtt�r Ef}fes.r+ejr.`'HUCTVOIN a sheets it necessary COMPLIANCE STATEMENT IA!`,D A[_L A CODECS t'is carmicate of comptanax lists me btAding lin and pertormance spetiticatlons nested t mpry wttn Title 24. Parts t and 6 a the Califama Corse of Reguattons, and tris ulattons inotvilw uteri overall design resu=Wsthrlity. Wttest is subattttted for a ongle budding plan to be Ut 0 multiple oriennaons, any shading teattue mat is varied is txkam to tits Special FeatureslRemams section. esigner r oyJrn (pw surer»" a Prokussww c"o) Documenta�thor rvaTe: ,.,�C� 7 Norm: TttlarFirrtt: IP4 ✓: /� TIWFirm: Adtlsss: 8 /�%¢/� yi-✓E� ldftss: %— S �---v 7,tl C Z7 rs►apnone: _ -/1- - 7 tdar) Enforcement Agency Nerr9s: rat,: Tewo m: _ 77j/_ - (owl, STATE OF CALIFORNIA—STATE AND CONSUMER SERVICES AGENCY PETE WILSON, Go»mor d Nc CONTRACTORS STATE LICENSE BOARD ata arornie 9835 GOETHE ROAD, SACRAMENTO, CALIFORNIA Deparsnerrtd MAILING ADDRESS: P.O. BOX 26000 COIISlIII1E 'I' SACRAMENTO, CALIFORNIA 95826 W (916) 255-3900 EXEMPTION FROM WORKERS' COMPENSATION Pursuant to Section 7125.1 of the Business and Professions Code, prior to issuance of a new license or reinstatement, reactivation, or renewal of an existing license, and as a condition of continued maintenance of an existing license, the applicant or licensee must have on file a Certificate of Workers' Compensation Insurance or a Certification of Self -Insurance from the Director of Industrial Relations. If the applicant or licensee has no employees, an exemption certificate must be submitted, certifying under penalty of perjury that he/she does not employ any person in any manner to be subject to the Workers' Compensation laws of California. A certificate or exemption is not required on an inactive ,license. _ COMPLETE THIS EXEMPTION CERTIFICATE ONLY IF YOU DO NOT EMPLOY ANY PERSON. NOTE: If the license is qualified by a Responsible Managing Employee (RME), an exemption certificate cannot be submitted. OUT-OF-STATE CONTRACTORS: If you do not hire employees who reside in California, check this box [ ) and send the completed exemption certificate and a Certificate of Workers' Compensation Insurance which covers the employees from your state who are working in California. Note: If California does not have a reciprocity agreement with your state, you will be required to purchase a California Workers' Compensation policy to cover your employees while working in California. PLEASE TYPE OR PRINT IN INK. FORMS COMPLETED IN PENCIL ARE NOT ACCEPTABLE. Send the completed certificate to the Contractors State License Board (CSLB) at the address above.' LICENSE NUMBER OR PENDING APPLICATION NUMBER B451035 FULL NAME OF BUSINESS (AS IT CURRENTLY APPEARS ON THE RECORDS OF THE CSLB) Alfred Earl Durrett BUSINESS HASMAD NO EMPLOYEES AS OF (MONTH/DAY/YEAR): 1/23/97 If this date is older than 90 des we will use the date the notice is received at our headquarters office as the effective date. DAYTIME BUSINESS TELEPHONE NUMBER EVENING TELEPHONE NUMBER ( 619) 771-3836 ( FALSIFICATION OF ANY DOCUMENT IS CAUSE FOR DISCIPLINARY ACTION On 1/23/97 Date - Month/Day/Year Palm Desert Riverside County CA at City County State I certify under penalty of perjury under the laws of the State of California that the above named business does not employ any person in any manner so as to become subject to the Workers' Compensation laws of California. I further certify that the CSLB will be notified and sent a Certificate of Workers' Compensation Insurance o Certification of Self -Insurance within 90 days of employing any person which results in the business becoming su a to the Worker Compensation laws of California. SIGNATURE OF OWNER, PARTNER, OR OFFICER. red E. Durrett PRINT OR TYPE NAME OF THE PERSON SIGNING THIS EXEMPTION WILL REMAIN ON FILE UNTIL YOU NOTIFY THE CSLB OF ANY CHANGES. PURSUANT TO SECTION 7083 OF THE BUSINESS AND PROFESSIONS CODE,.FAILURE TO NOTIFY THE CSLB OF ANY CHANGES WITHIN 90 DAYS IS GROUNDS FOR DISCIPLINARY ACTION. 13L-50 (Rev. 5/95)