0301-295 (BLDG)LICENSED CONTRACTOR DECLARATION
y I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 dt the bU6Ihd69 Arid
04 W Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
r-
t*_ Z Date Signature of Contractor
O
JU 6 ,OWNER -BUILDER DECLARATION
H LU r- 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
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
C'') () I am exempt under Section B&P.C. for"this rea'`Or
O Nabate �! 3- ?Signature of Owner,...` 1 _
-..._
Q WORKER'S COMPENSATION DECLARATION
a
o Z 1 hereby affirm under penalty of perjury one of the following declarations:
LO cc
O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W Y=compensation, as provided for by Section 3700 of the Labor Code, for fFie-
O J Q performance of the work for which this permit is issued.
co Q U �( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
a:rn i— permit is issued. My workers' compensation insurance carrier & policy no. are:
v Z Cartier 87.A+'r`' , FLIN Policy No. PM601U!-.0C+009415
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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 3 00 of the Labor
Code, I shall forthwith comply with those 'rovisions /
/Date: / '-�/ • " :, Applicant 4._... :!'� r ,
Warning: Failure to secure Workers' Compens tion coverage is unlawfJ-aCrid.
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 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. '
r Signature (Owner/Agent) • ', —DateJ�1 -
PERMIT#
BUILDING PERMIT
DATE J i VALUATION 1 LOT I RAL, I
JOB SITE
ADDRESS C .� C.76 �.„9. C'. i� '��'�O er0 iz C}eddL h : f4
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
.
PAW,* u,t �ei;SK1b3;ir1.AL ASSOC, y.NC,'
4J_ MAk pfNCT 1
3577 SQV111: C-Cp>' :fit 250.
L,iif17>)"%'F: t;p�nj�o
r:'l�i 1�7�`F k3 ,>9?~ %,4.'2�'/UI
USE OF PERMIT
u"•L-iXt E_ti: 54•40% S/d.,45, 54.44A 54.432. of O'L-a_tNTPR Y
i
1033 Ot'fC1-414.000 2045,1.4111
S'tWYNI(le'1nd)°[IGN'ti'KK RP4;il) 10 1 -000- 241 -M)
FEB 0 :�UINTA 03 .�?
CITY•OF'LFINANC.
Jr�K<�.".CJv�r�C'�P'UL'1(� 5W11I:�Y' f1l��11, "t,:
�C
RECEIPT
DATE
BYKTp` ^„
DAf A E
INSPECTOR