04-3550 (BLCK)P.O. BOX 1504 •
VOICE (760) 777-7012
78-495 CALLS TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number: Date: y 2 -
Applicant
Applicant's Mailing Address:
06
Architect or Engineer.
NoNF
.Architect or Engineer's Address:
Uc. No.
BUILDING PERMIT DECLARATIONS .
affirm under LICENSED CONTRACTOR'S DECLARATION
I hereby affirm
Penalty of perjury Mat I am ficened under provisions of Chapter a (commeenang with Sectio; 7000) of Division 3 of the Business and'Professionats
Code, and my License is in fun force and effect
License Ck'sslicense No.�('— �T—
1 c
Co.
$1.111LDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the following reason (Sec. 7031.5. Business and Professions Code: Any
city or county that feWres a permit b construct, atter. Improve, demolish, or repair any strowme, prior 10 its issuance. also requires the applicant for the permit to kle a signed
statement that he or she Is kensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business
and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects
the applicant to a civil penalty of not more than five hundred dollars (5500).):
U I. as owner, of the property. or my employees with wages as their sob compensation, will do the work, and the structure is not intended or offered for sale (Sec. mp7044,
Business and Professions Code: The Contractors! State License Law does not apply to an owner of property who builds or iroves thereon. and who does the work
himself or herself or through his or her own employees, provided that the improvements are not Intended or offered for sale. If, however. the building or a,provement is
sola within one year of completion; the owner xulder will have the burden of proving that he or she did not build or improve for the purpose of sale.).
U 1. as owner of.the property. am exclusively contracting with licensed contractors b construct the Project (Sec. 7044, Business and Professions Code: The Contractors'
State License. Law does not appy to an owner of property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
the Contractors' State License Law.).
U I am exempt under Sec. . B.6 P.C. for this reason
Date ` Owner
WORKERS' COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarafios:
_ I have and will maintain a certificate of consent to setNrsu a for workers' compensation. as provided for by Section 3700 of the Labor Code, for the performance
of the w 0 k for which this permit is issued.
_ 1 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
My vlZke
Cartier �'/�e�P ,--I`3 rs, cogwenation Insurance carrier and policy number are:
—sL 4 <L- Policy Number
I certify that, In tha performance of On work for which this permit is issued. I Shan not employ anyperson in any manner so as to become subject to the wockers'
compensation laws of CaRomia, and agree that, If I should become subject b the workers' compensation provisions of Section 3700 of the Labor Code, i shag
forthwitm.conply with those provisions.
Date 2I�o AppkM G .
WARNING: FAILURE TO SECURE WORKERS COMPENSATION C04AOE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100.000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, tJTEREST, AND ATTORNEYS FEES. .
CONSTRUCTION LENDING AGENCY
1 hereby affirm under penalty of perjury that there is a construction bndmng agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application Is hereby made to the Director of Building and Safety for aper* subject to the conditions and restrictions set forth on this application.
I. 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 application, the owner. and the applicant, each agrees to, and shall. defend. indemnify and hold harmless the City of La Ouinta, its
officers. agents and employees for any act or omission related to the work being performed under or following issuance of this pemnit.
2 Any permit issued as a result of this alication b
application null and void if wok 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.
1 certify that I have read this application and state that the above tnforma . is cared i agree to comply with all city and county ordinances and state laws relating to building
construction. and hereby authorize representatives of this county to a the above-mentioned property for Inspection purposes.
Date L Gf� Signature (Applicant or Agent):