9905-183 (RPL)LICENSED CONTRACTOR DECLARATION
CO I hereby affirm under penalty of perjury that I am licensed under provisions of
i.;-- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04:LOU -Profes�ionals Code, and my License is in full force and effect.
�; =) . License # Lic. Class Exp. Date
P_ 0 LO
LU
r— Date Signature of Contraactor
6 r-
0. r-. .7
I.— C:1 OWNER -BUILDER DECLARATION
_J 0. CID
UJ LU I 'hereby affirm under penalty of perjury that I am exempt from the Contractor's
a_ License Law for the following reason:
U)
z J, 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).
1, as owner of the property, am exclusively contracting with licensed
contractors to'construct the project (Sec. 7044, Business & Professionals
Code).'
am exempt under Section B&P.C. for this reason
LO
C\l Date Signature of Owner
0 C\l
< WORKER'S COMPENSATION DECLARATION
CL
Z
cc I hereby affirm under penalty of perjury one of the following declarations:
.0 1 have and will maintain a certificate of consent to self-insure,for workers'
0
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compensation, as provided for by Section 3700 of the Labor Code, for the
peHormance of the work for which this permit is issued.
J., <
< L) XX� 1, have.and will maintain workers' compensation insurance, as required by
ot - 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:
7T darrier Policy No.
00 i
S ATEV W 1230
(This section need not be completed if the permit valuation is for $100.00 or less).
ertify that in the performance of the work for which this permit is issued,
I all.not employ any person in. any manner I so as to b
'sh ecome subject'to the
workers' compensation laws of California, and agree -that if I should become
kbject to the workers' compensation provisi�ns,dfl�ectid'n 3700 of the Labor
C6cle,� I shall forthwith comply Qth thoseprovis`6`ns.��
Date: Ir, Qe? A nli'r.'Ant 1,�w�le
J f. -I
Warning:. Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employcr to criminal penalties an ' d civil fines up to $100,000, in
addi , tion'to the cost of compensation, damages as provided for In Section 3706
00he Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
fo,r 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.
12. 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
per , mit, 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 pr�perty for inspection purposes.
(Ownle Date
Signature
r;,Agent)
PERMIT#
BUILDING PERMIT
9905-193
DATE,,, VALUATION $11,00tI.60 LOT TRACT
JOB SITE I
APN
ADDRESS 5�665GHANID A -ASE AVE,
T% VT
OWNER
CONTRACTOR DESIGNER ENGINEER
VJT 1101%.1.11311%, LAIC
f
PO BOX 810
1425'E. uNivikirry' I)Riw
LA QUWA CA. 9225.3
PHO'IFNIN AZ 85034
(602)2VI746M CBL# 4990
USE OF PERMIT
POOL AND/OR SPA
PC)OUV A. XLARMSiSAMEAS 814AL L BEM AT VRE�PL AST M -
POOL ANDIOR SPA 11,0W.0011's
ENITMATED ctwr OF CONSTIM1114.710N
1,110O.M.
PERNIff FEESUMMAMV
P LA14 CHECK FER, 101-000-439-318 :53 L90
CONSTRUM-16N FOR, $1,2600
MECRANUCAL FLX POOL $2-4.00
P6GL �101-011%1-420-000
GLEC t45.00
PLUMBNO Fli'H P001. 101-000-419-000 %27.00
SUB -TOTAL M.NS!V'JCT[0NAXD PLAIN CHIECK
LESS PRE -PAID FELIS
TOTA'L PERAWIT VxVE8 DUE, N(YVV
RECEIPT
DATE
BY
FINALED TiNSPECTOR