04-3649 (MISC)P.O. BOX 1504 QUA& VOICE (760) 777-7012
7E-495 CALLE TAM►ICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number. r- 36 ' Date: -5 S O
Applicant: Architect or Engineer
Applicant's Mailing Address: Architect or Engineer's Address:
Lic. No.
BUILDING PERMIT DECLARATIONS
LICENSED CONTRACTOR'S DECLARATION
I hereby arum waw POOKy at perjury that I am licensed under provisions of chapter 9 (commencing with Section 7000) of Division 3 of the Business and I'MiessionsIS
cLioens° kA lo°e and A ON r �i== No. %d 103
�• S5t�f d,CorNrador ��s V� Hoh�Si�hS,��
OWNhR•BUILDER DECLARATION
1 hereby affirm under paelty of perjury that 1 am except from the Contractors' State License Low lor the fofowirhg reason (Sec. 7031.6. Business and Prohssions Coda: Any
city or mn-Ay that repuM a permit to cm*uaL aper. improve. demoistL or repair any ouctum prior b Its issuarhm also requires the appicarr for the pumA to fie s• signed
statement that he or she lsfoamed pursuant b the, provisions of this contractors' Stab Lieeree Law (Chapter 9 (cortnrencing with Section 7000) of Division 3 of the Business
and Prolessions Code) or that he or she Is exanpl Uhaetonh and the basis for the afeged exemption. Any vioiaW of Section 7031.5 by" appieaM far a perm subjects
the applicant b a civil penally d not more than fve hundred dofars (5500).):
U Las owner of the property. or my ernployees with wages as their sole compensation, will dole work, and the structure is not intended or oAaed ter sate (Sec. 7044.
Business and Professions Coda The Contractors' State License Law does not appy to an owner of property who builds or improves therean. and who does the work
himselfor herself or thuough his or her own employees, provided that the improvements aro not intended or aft ter sale. lf, howeyer. the biding or improrenrhed is
sold wiUrn one year of completioN the owwer4puider will have the burden of p oviq that he or she did no brill or improve ter to purpose of sate.}
U 1, ss owner d ter property. em exdusively conYacb with licensed cont acbrs to construct the project (Sec. 7044. Business and Pidesslons Code: Tie ComrectoW
Stab L loense Law does not apply b an owner of property who bolds or improves •nereoh. and who Couhtrads for the projects with a Contrector(s) ioahsed pursuarN b
the contractee' State license Law.).
U I am exempt under Sec. . B.& P.C. for this reason
Date—owner
WORKERS' COMPENSATION DECLARATION
1 hereby affirm under penalty d perjury one of" fobwing declarations:
—I have and will maintain a certificate of consent to selfinsure for workers' compensation. as provided for by Section 3700 of the Labor Code. for the performance
of the work for which this pem* is issued.
1 have and ori« maintain workers' compensation insurance. as required rd Eby Section 3700 d the Labor Code. for the performance d the work ter which this permit Is
� Vl1*n` compensation .haunter /ti l S r aro:
_ I catty that, in//th�e� performarwca of ane wok for which this permit is issued, I"not enpby any person in any manner so as to become subject to to workers'
con maskm laws of California, and agree that. M 1 should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, l shall
krewft comply with Arose provisions.
WARNING: FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED THOUSAM DOLLARS ($100.000). IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 3705 OF THE LABOR CODE, INTEREST. ANO ATTORNEY'S FEES. .
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty ofthat there is a Construction lending agency for the performance of the work for which this permit is issued (Sec. 3097. Civ. C.).
Lender's Nannie
Lender's Address
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application Is hereby made to the Director of Building era Safety for a permit subject to the Conditions and restrictions set forth on this appkal'ion.
1. Each person upon whose behalf this application is made. each person at whose request and for whose benefit work is performed under or pursuart to any permit
Issued es a ftu* of this application, the owner, and the appficsM, each agrees to. and shag, defend. indemrfify and hold harmless the City of La OukNs. les
officers. agents and employees for any ad or omission related to the wok being performed under or fodowii g issuance of Urs Penni
2 Any permit Issued as a result Of this application becomes null and void 9 is not Commenced within 1.0 days from date d issuance d such pan or
mastion d work for 160 days will subject permit to
1 certify that I have read this aWkstion and state that the shove ill on 1 to comply with of city and County ordinances and state laws rotating to building
construction. and hereby authorize representatives of Urs county b er a -mentioned property for Inspection purposes.
JiDate J S' 4 !OS, (Applicant or Apert): 1-7