0208-092 (RR)LICENSED CONTRACTOR DECLARATION
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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
235717 C-39 B IEC 1/31103
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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).
() 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:
() 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 "issued.. My workers' compensation insurance carrier & policy no. are:
Carrier STATE FUND Policy No. 0457624-02
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that.in the performarice 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 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
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 foK 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.
Signature (Owner/Agent)
Date
r PERMIT #
BUILDING PERMIT 0208-092
DATE VALUATION 914,877 00 LOT TRACT
JOB SITE APN
ADDRESS BLDG. 17 PEBBLE BEACH aA
OWNER CONTRACTOR / DESIGNER / EN 1NEER
PGA WEST RESIDENTIAL HOIVIEOWNER'S E WESTERN PACIFIC ROOFING
PO BOX 1060 3462 LA CAMPANA WAY
LA QUINTA CA 92253 PALM SPRINGS CA. 92262
(760)416-5877 CBL4 4293
USE OF PERMIT
GENERAL BUILDING
POLYURETHANE FOAM &ACRYLIC COATI -14(3 R00FIX0 SYSTEM
VALUATION
14,877.00 LS
ESTIMATED COST OF CONSTRUCTION 14,877.00
PER 41T FEE SUAUViARY -
.REROOF FEE 101-000-418.000 $30,00
SUB -TOTAL CONSTRUCTION AND PLAN C''HECK $30.00
' LESS PRE -PAID FEES $0,00
TOTAL PERMIT FEES DUE NOW 1 $30.00
RECEIPT I DATE i BY I DATE FINALED I INSPECTOR