0307-209 (TRELLIS) LICENSED CONTRACTOR DECLARATION
PERM
BUILDING PERMIT 1 0307-209
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 DATE VALUATION ,$12,289,20 LOT 285 TRACT 24230
Professionals Code,and my License is in full force and effect.
License# Lic.Class - Exp.Date
184531 B C-8 HIC 7/31/03 JOB SITE 78-873 AVENUE 47 TRELLIS#1 APN 643-090-014 1
• ADDRESS
Date Signature of Contractor OWNER CONTRACTOR/DESIGNER/EN (NEER
SCPH ROEL CONSTRUCTION CO.,INC. `-
OWNER-BUILDER DECLARATION 516 BURCF=STREET 78-401 HIGHEAY 11195 LA QUINTA CA9211 53
I hereby affirm under-penalty of perjury that I am exempt from the Contractor's GLFDIDALE CA 91203 SAN DIEGO CA 92138-0: �
License Law for the following reason: (619)297-4156 CBL# 3687
( ) 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). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed GENERALBUIL]NO
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt under Section , B&P.C.for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations: PORCH/PATIO 924.00 SF
( ) I have and will maintain a certificate of consent to self-insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit,is issued. -�
( ) I have and will maintain workers'compensation insurance,as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is isgued. My,workers' compensation insurance c mer & olicy no. are:
Carrier zunch am6hcan Policy No. 1VC367619-00 ESTIMATED COST OF CONSTRUCTION . 12.289.20 '-
PERMIT FTE SUMMARY
(This section need not be completed if the permit valuation is for$100.00 or less). CONSTRUCTION FEE 101-000-418-000 $144.00 1
( ) I certify that in the performance of the work for which this permit is issued, PLAN CHECK FEE 101-000-439-318 $107.46
I shall not employ any person in any manner so as to become subject to the ELECTRICAL FEE 101.000-420-000 $18.00
workers' compensation laws of California, and agree that if I should become STRONQ MOTION FEE-RESID 101-000-241-000 $1.23
subject to the workers'compensation provisions of Section 3700 of the Labor GRADING FEE 101-000-423.000 $15.00
Code,I shall forthwith comply with those provisions.
Date: Applicant _
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 Y•ti
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 SUB-TOTAL CONSTRUCTION AND PLAN CHECK $285.69 !:�1i1
whose request and for whose benefit work is performed under or pursuant to LESS PRE-PAID FEES $0.00
any permit issued as a result of this applicator agrees to, &shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees. TOTAL PERMIT FEES DUE NOW 528 .69
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 11111111 IIIII III IIIII IIII 69
correct. I agree to comply with all City, and State laws relating to the building IE
construction, and hereby authorize representatives of this City to enter upon,
the above-mentioned property for inspection purposes. — - --
RECEIPT DATE BY DATE FINALED INSPECTOR
Signature (Owner/Agent) Date