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 MC 1/31/03
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,' Busiriess & Professionals
Code).
O I am exempt under -Section B&P.C.'for this "reason
Date Signature of Owner,
WORKER'S COMPENSATION DECLARATION
I her eby. affirm under penalty, of "perjury one of the following declarations:
O 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: 0437624-02
(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,
kshall not employ any person in any mariner so as to become' subject to the
workers' compensation laws of California, and agree that if I should become
subject to :ttie=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 thelabor 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 upori
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
PERMIT #
BUILDING PERMIT
0208-092
DATE VALUATION $14,877.00 LOT TRACT
JOB SITE
ADDRESS BLDG. 17 PEBBLE BEACH 80 _ Z
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
PGA WEST RESIDENTIAL HOMEOWNER'S
�c WESTERN PACIFIC ROOFING
PO BOX 1060
3462 LA CAIVIPANA WAY '
LAQUINTA CA 92253
PALM SPRINGS.. CA 92262
(760).16-5877 CSL14 4293
USE OF PERMIT
_GENFR AL BUII ;DING
BLDQ.17; 80.504, 80?112, 80•,5207 80.528:: RE. ROOF.WITH .
POLYURETHANE FOAM -&ACRYLIC COAT1140 ROOFINO SYSTEM
VALUATION 14,87700 LS;
ESTIMATED COST,OF CONSTRUGnON
14,877.00
PERMIT FEE SUMMARY
REROOF FEE 101.000-418-000 $30.00
SUB -TOTAL CONSTRUCTION AND PLAN CI=
$30.00
LESS PRE -PAID FEES
$0,00
TOTAL PERMIT FEES DUE NOW
$30.00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR