0109-169 (RR)N 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
N W Professionals Code, and my License Is in full force and effect.
O 5 M License # Llc. Class Exp. Date
W 770940 C39 11M 11/39/0)
d Z Date Signature of Contractor
1OWNER-BUILDER DECLARATION
WW :I hereby affirm under penalty of perjury that I am exempt from the Contractor's
CL
N 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). p.
O O I ampt nder Section , B&P. .for, hjs res on lei
Date 4��4 P Si nature of Owner
rn
a Q WORKER'S COMPENSATION DECLARATION
O � QI hereby affirm under penalty of perjury, one of the following declarations:
p () 1 have and will maintain a certificate of consent to self -insure for workers'
X W LL 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 U ( ) 1 have and will maintain workers' compensation insurance, as required by
O � Q Section 3700 of the Labor Code, for the performance of the work for which this
a H permit Is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
tCO ` O 3TATIS FUND 28$40-001997
g (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
subject to the workers' compensation provisions of Section 3700 of the Labor
3 . Code, I,sh II forthwith comply with thos , rovisio is
Date: t. Applicant �_ r•!
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, indemnify
& 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 1 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.
Signature (Owner/Agent) / `A ,/ A 141 Date -Z
BUILDING PERMIT - -
DATE VALUATION LOT ��-it� TRACT
JOB SITE
ADDRESS
APN
V
OWNER
CONTRACTOR DESIGNER ENdIINEER
f.
r RR89.t[i��'T!'AL HOMW�1V1�tM
PGAp�
8 RMtAi«T?INC.
{�
.Ij,O,BOX 1060
/RO�OMO,
8349'1 PFACH ST,
LA QIYWA CA
DW10 CA 92201
0160)347-9869 CMIA 3978
USE OF PERMIT
C1R?7l:RAI. BUIL.DINO
R PLROOP WITH CLASS A MXtZRLA.LS -1IL 0. 36: 34.36X.Si4 3M
34-341, 94�0Ssiet
VALUATION 1,500.00 LS
NS VAAIXD COST OP' COJIMMUCU011
PIMM FFX NUADIARY
RNOOA FRE 101-000.418.000 030,00
t •�
PFSEP18
2001
CITY OF LA QUINTA
FINANCE DEPT.;
f
3LIk3-`i arAL G' NSfmUCT)IOx ANT' PLAN cwzK 4
$30.00
I1=1 PR19-PAID MW
50100
FAL MWIT M6 DUE 14OW
Sm"
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR