9708-075 (BLCK)�_.. •.6 .
LICENSED CONTRACTOR
DECLARATION-•
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Uj ..,•..: I,lrereby•atihrta under penalty oi'perjury That Ferri. licensed Itradrjr pnovislot►s ot;�'_ - ;.x,='ti•;; `,: ;1,-,:::.,,:,�: -:��;,.. -
�, m BUJLOING.PERAAIT::'`::--
apter ( ening with Section 7000) of Division 3 of the Business arid._ -
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N : vala?ani lot -: ;.::,
Professionals Coda and m License is in fuB force and �eltec4 _ .: n+Acr
CD • ot,C? • a ' - -
p M.,' Licettse'�t. e: lac. Class- Oats'• —3. 5 _S ;i '
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c 20. ti ' e' Signature of Contractor 9WNEH . oonrtA,ocrortroEsrcNEn r x
C' t` a Ault.',etc
m U m , :: ..' • : ' UILDER E LARATION , CARADAY &'Gd14tPANY AtAI)AY di 'CO, A . '
OWNER -B : „.=•:�•.; �; ..<
F w w'� ' .' I.laeretiy affirm under anal of perjury haat I am _ t 1570 6ROOKNQLi.6W DRM SUrrE 208' . 1 S90 8A0l3KHOLUDW D
exempt from the ContractoYs RIVE; SUl7� 2Q$ .
O �' License Law for the following reason: SANTA ANA CA 42 05 SANTA ANA: - F: CA 927
Z (:) . 1, as owner of the property, .or my employees wiUi wages as their. sole
(7I7SI-91iS1
compensation, will do the work, and the structure. is not Intended or offered for
m sale (Sec. 7044, Business & Professionals Code). USE rF PEAMrr '
a ( } - I; as owner of the property, am exclusively contracting wrth licensed t
N contractors to construct the project (Sec. 7044, Business & Professionals Bi''G��' '
Code)...
() I am exempt under Section B&P.C. for this reason tfird UN v I OF S HOW Al Z ?64 L N FT CW 4 F'T t3Ud '
,.
0 Date Signature of Owner
WOAiitH'S UUMPENBA'i'IION DECLARATION
QZ I hereby affirm under penalty of perjury one of the following declarauons; 6
H 0 () 1 have and wig maintain a certificate of consent to wif4nsure for workers' y V7. WALL 89.00 L1;
< ui J compensation, as provided lot by Section 3700 of the Labor Code, for the d FT. WALL �
� _J edormance of the work for which Ibis
p permit is issued. sV
Q I have and will makdain workers' corn pwisatian insurance, as required by ,
tJ Q Section 3700 of the tabor Code, for the perfomrance of the work for which this
H permit is issued My workers• compensation nuance carrier & policy no. are:
z Carrier Policy No...
co
CO tIri'lCAt2BlI+ISCO ^2SU119b1d1;s9 1�.4TlA2A1>�'DCb$7Off'C0 331QiJCT
L 01his section need riot be completed it the permit valuation is for $100.00 or less). PE�RMff FKE SUUMAJMY
� (,) I certify that U"the performance of tfre viork for which d" permit is issued, COAdMUCCf N k'EB 101-00016.000 g
1 I shall not -employ
m • arty person in arty manner so as to. beoome subject to the . _, S, .; :::•;
workers' compensation laws of Cagfomia d ail that 1 should become
subject t workers' borrm nation
pe 3700 "ol the r `'-c. ; :. � .;: � ,.::.: :;•.
� :1.; -till :, ; .i :;';•� .
O comply will►
3
WAppi
cnWarning-r..: ,, :ati
- Failure � secure�F.
LO Compensation coverage is unlawful
shall subject an employer to criminal penafties arid CvA fines u to $1
add3tloua lo the cost of compensation, damages as -provided for In Section 3706
Of me Labor Code, Interest and attorneys fees �`n:.L'];!._?:.^ :.
Appel cation is hereby made to the Director of Build an u' � � y..•
m IMPORTANT i Ing d Safety, J - ; J: ° • ' ' ..5�> - , : .:
(or: a units subject
M pe uf>i 10 the.00nditeons and restrlotions Set forth his - - .Jz'= '�e+,:3t'^' •�'�. -
' appNcation.
1 1. Each whose behalf
� person upon this application is made 8� each person a1. -
.� whose request and for whose benefit work is erformed under or u
� P p rsuantto .:r:".. r. .:• ;�y.;�^;.:,�:;;r:.;��4
any permit issued as a rosult of this applicaton agrees to. 8i shall, indemnify . UB -TOTAL C:t'JN rmuG'noN-AND At:eat
& hold harmless the City of la Qulnta, its officers, agents and emplogees. :.1tE ` f,
. 2 Any permit issued as a resufl of this a lfcation
becomes !.' = i '
PP mss null and Vold H'` : •:': - .+ a•+?- :.:-: `'> ,�,s:4: ra.T a,`1` ,r:
i4ork is rat commenced' within 180. da }torr; da
days le of issuance �of sudr`� •��: �: , .�' �:':T �, � T°;; _ _s
permit, or oessallon.oi work for 180 da will stiti'ed emal to catuoefl ton: 7.ti1'A>�,' .F �v •� _
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v
certifythi
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11 re :Y
a have ad •�9'
this a 'carinii and e� the >�` N-. �'<� at: ; • -�:
PPti sial that above iMormadon rs:: ... _ .;�rLL�� 7hr ;,:�e.�,•�. .r {k.
act:.
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torrcomply.•'rte-. ..cs
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wit all C" �-
nd to 4•'��'.
agree aws `r t
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Std to the: briild
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nictio and h -
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assn •this �
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Si nature OwnerlA tnrAeDATE
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