0110-098 (BLDG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
HChapter 9 (commencing with Section 7000) of Division 3 of the Business and
cv W Professionals Code, and my License is in full force and effect.
O th License # Lic. Class Exp. Date
LO
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~o Z Date Signature of Contractor
r9Ot
J U � OWNER -BUILDER DECLARATION
HWW r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) 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, ^usiness & Professionals
Code).
C'•) () I am exempt under Section , B&P.C. for this reason
N Date Signature of Owner
O CV
a Q WORKER'S COMPENSATION DECLARATION
o � I hereby affirm under penalty of perjury one of the following declarations:
Lo F2 O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= 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.
ED Q U ( ) I have and will maintain worke.s' compensation insurance, as required by
O � Q Section 3700 of the Labor Code, for the performance of the work for which this
Cn H permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Carrier 1. Policy No.
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Q (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
Code, I sh l forthwfth comply with those pr visior3s.
Date: '1 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, dama,fes 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 fnspectfon purporses.
Signature (Owner/Agent) r' Date
BUILDING PERMIT PERMIT k;
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS .... ,.)'..1.i•<�•.i..�a; ��—��'�
-
OWNER
CONTRACTOR/DESIGNER/ENGINEER
POA W%'X1' k1~ W,LVgMAL ASti300A'I'ION
r?r L MM' .PAOWW 43WER A.l, C(.fNVJk,(`P
Pi) 11M ] 060
462 :1rEVM ,9 AV& NiW
"A Q11DJTA i.'A 92253
�WPLANA fiEP.CH CA Y2075
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USE OF PERMIT
WIM71AS.W.F01is
7S.160 3T. CIJA "VES FIJI
[:i[Gi, i5-41sii S3.5;6 &_55•556 OAK 1114 F • # UHITN'NO5, TF1 it
7Vift •t3h1'YAitY S`E'RUCTItIi?AI. M,'D 71110A110)1%3
VALUATION AM. Do U)
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RECEIPT
DATE ,'
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
r_iPERATION I
DATE
I INSPECTOR
❑PERZATION
f DATE
I INSPECTOR
CWLDING
APPROVALS
I MECHANICAL APPROVALS
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