9906-165 (RR)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
255T17 C-39 o>tr
l ` '' f2a
`/ y
�
1T'- Signature of Contractor`- =
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, 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).
( ) I,. 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 certificate of consent to self -insure for workers'.
compensation, as provided for by.'Section 3700 of the L.gbor Code, for the
performance of the work for which this permit is issued.
PQ 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 issued. My workers' compensation insurance carrier &'policy no. are:
Cartier Policy No.
S°TAM FL N17) 1424240-98
'(This section need not be completed if the permit valuation is for $100.00 or less).
( ) 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 I should become
subje t to the workers' compensation pr visions of Section 3700 of the Labor
C e, I hall forthwith comply with tho " pr IsI
ate: ' ' Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer 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 attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for 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, A shall, indemnity
& 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 commenced 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 inf6r#nation is
correct. I agree to comply with all City, and State laws relating to the building
cons uction, and hereby authorize representatives of this City to enter upon
ZIthegn
bove mentioned property for inspection purpga�es.
ature (Owner/Agent) . '' ✓ r� Date > `
PERMIT #
BUILDING PERMIT,_____.__:..:
DATE Q( 22f.J"VALUATION 533,442.90 LOT
TRACTJOB
SITE
ADDRESS 43-UOU42 VISTA DE NOPA L 77—
OWNER
CONTRACTOR / DESIGNER / ENG114EER
LA. GUNA DE LA PAZ
WV.EWERN PACIFIC ROOFING
48-100 VISTA LAGUNA
302 LA CAMPANA WAY
LA QUINTA CA 92253
PALM SPRINGS CA 92:262
(70)416-5147'' C B L # 4:93
USE OF PERMIT
ENFRAL RUI )NO
RE -ROOF
REROOF 13,442-00 LS
ESTIMATED COS; OF CONSTRUCTION
13,442.1e
PERMIT FEE 5il#iifiVlARY .1
REROO FEE
S1.113-T(yr,kL roN 0ALK-InION AND PLAN ('I-IEOK
S _no
LESS
DESS PRE-PAJD PEES
$fl.00
TOTAL PERMIT FEES I)U Is NOW
S.Itl,f;'0
DATE
BY r
DATE FINALED
INSPECTOR