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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
1(,'36 1
F A,�
Sig
/r,.I r
Date nature of Contracto.
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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 & Professionals Code).
( ) 1,1 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 ce ' rtificate of consent to self -insure for workers�
compensation, as provided for by Section 3700 of the Labor Code, for.th e
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 t
ps�ed kgp�.?,p rrier & policy no.. are:
,% I ,,0YyyWr, . 'pensation insurance ca
Cartier . Policy No.
(This section need not be completed if the permit valuation is for $100.00 or I ess
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 ZIshould become
subject to the workers' compensation provisions of Section"3700 of the Labor
Code, I sha I fo with comply with those proVtsiong�"
Date- Applicant Ire 4 A
Warning: Failure to secure Workers' Compensation covef ge is unlawful 'and
shall subject an empjoyer 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 aftorney,s fees.
IMPORTANT Application is hereby made to the Direcior of Building and Safety
for.' a permit subject to the conditions and restrictions set fortli on his
application.
1. Each person upon whose behalf this applicaflon 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 commended 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-f—ppresentatives of thrs City to enter upon
the above-mentioned property forinspe tion pdrposeg
I �X
ZX
IAdSignature (Owner/Agent) . d , A Date
BUILDINGPERMIT PERMIT# CONTROL#
9"7-009 3652
DATE VALUATION LOT. TRACT
-7/ V96 %300.00
JOB SITE
APN
ADDRESS 53-1911 AVE N I DA HERkCi RA
-774-163-022
OWNER
CONTRACTOR DESIGNER ENGINEER
JA
CORTEZ & ASSOC ITS
S3911 AVENIUKHERRERA -
130-52 CEDAR Sf,
LA QuafrA, C A' ',Y22 53
HESPERLA, CA 92-345
(
(60)951-3363 coffi 382 1
USE OF PERMIT
WXJ70?. TIEKIT-k CHANOE (XIT
300.00
PRE
PL I LtMAINGIFLE' 10 140-419-00,11
>11
S03410a"Af. CON.-TIRUC.riON AND PLAN CIIECK
$22.50
I.,ESS PKE-P AJD FRES
$0.00.
TOTAI, P14MI[TIKERS 011KNOW
S22.io
RECEIPT
DATE
BY
DATE FINALED. .
INSPECTOR