0109-169 (RR)N I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
0y co Professionals Code, and my License is In full force and effect.
dM License # Uc. Class Exp. Date
LLi
ll' 7700.40 C39 MC 11/30101
ZO Date Signature of Contractor
J V OWNER -BUILDER DECLARATION
W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for.the following reason:
Z ( ) 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
ontractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am ex pt vender Section , B&P. fpr his rea on1011
O Date l Signature of Owner✓ `
U Q WORKER'S COMPENSATION DECLARATION'
W 1 hereby affirm under penalty of perjury, one of the following declarations:
r H O () I have and will maintain a certificate of consent to self -insure for workers'
X W !L compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q V ( ) I have and will maintain workers' compensation insurance, as required by
O V Q Section 3700 of the Labor Code, for the performance of the work for which this
0)Z permit is Issued. My workers' compensation insurance, carrier & policy no. are:
It _ Cater i Policy No.
cb O 3T,ATEFUND 383-11 tW0t99�91
g (This section need not be completed ff 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
subject to the workers' compensation provisions of Section 3700 of the Labor
3 Cod@, I,shall forthwith comply with thos rovisio s,
Date: � ' Applicant +,T �✓
�.:. 4 4
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, & shall, Indemnity
ICU & hold harmless the City of La Ouinta, Its officers, agents and employees.
2. Any permit Issued as a result of this application becomes null and void if
work is not commenced wit hln 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 representatives of this City to enter upon
the above-mentioned property for inspection purposes.
�` _ Date /E
Signature (Owner/Agent)''
WILUINU rtKMii
DATE VALUATION LOT OIW169 TRACT
simm
JOB SITE
ADDRESS57
� / /,3A �s
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
PGA VWT �� 1yi0MOVI Mfl A
83 S,MMALD ROCIMG, WC.
11.01BOX 1 %0
83-597 PEACH 11'1'.
LA QUID TA CA
DW10 CA 42201
C760)347.9869 CBLA 3978
USE OF PERMIT
(3S UM AL BIMM)NO
N1&RCICIPWITH CLASS MA.TF.R.i:A.LS • BL1X 36: 54.363, 54.M
54-341, $4405
VALUATION 1,300.00 LS
F5' A1A4 T= Ct: Ff OF CONN INiJMON
1.5MIXII
P)Mh"'FKE NUMMARY
WOOF Fly 101.000.418.000 � $30.00
$ r �
I,&\
SEP 18 2001
CITY OF LA QUINTA
FINANCE DEPT. -
EPT.-Sif.13-TMAL
SIM TMALCt NlMU1M01; PND PLAN CHECK 'J J
$50.00
L= PRE431A l PM
$0.00
TOTAL P1R11T FEES DIE HOW
$ 30"
RECEIPT
DATE
BYDATE
FINALED
INSPECTOR
/