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(IN003H N01103dSNI
LICENSED CONTRACTOR DECLARATION
U) 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
c4 W Professionals Code, and my License is in full force and effect.
�; ma//ry-yy C) License # 7 Lic. Class Exp. Date
ftn
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X
oZ t-- r+Date— Signature of Contractor—
(00 1�
ontractor (0pt�
J U CD
C) OWNER -BUILDER DECLARATION
HWW 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, Business & Professionals
Code).
co () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
0)CL Q WORKER'S COMPENSATION DECLARATION
It ZCr I hereby affirm under penalty of perjury one of the following declarations:
Lo
p () 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.
m Q C) ( I have and will maintain workers' compensation insurance, as required by
Q LO U Q Section 3700 of the Labor Code, for the performance of the work for which this
CCpermit is issued. My workers' compensation insurance carrier & policy no. are:
�t Z Carrier Policy No.
CCD 0 ','°k° J7 FOVI11 IN
0
J (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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those, provisions.
trate: Applicant–
Warning:
pplicant 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
4 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.
VS/ignature (Owner/Agent)" Date
BUILDINGPERMIT PERMIT# CONTR(O''L��#
;
�
DATE VALUATION LOT TRACT
`81�27
A
7/q 6
JOB SITE#
ADDRESS
t
APN
t3'f'�t i� li l9dt r
OWNER
CONTRACTOR/DESIGNER/ENGINEER
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99
USE OF PERMIT
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR