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 HIC 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).
( ) s. 1, as owner of the property, -am. exclusively contracting with licensed
contractors to construct, the` project' (Sec: 7044, . Business &Professionals
Code).
O I am exempt under Section ' B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I :fiere6y, t
affirm under Jpenalty of perjury- one of he following declarations:.
( ) I have and will maintain a certificate of consent to self=insure.for workers'
co lip nsation, :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 3.700 of. the Labor Code, for the performance of the work for which this'
permit, is issued:My,.workers"compensation'nsurance: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).
( ), Fcertlfy that ln:the performance of the.work for which this permit..is issued,
Ishall not,employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if:l should become
.subject to ttie workers' compensation provisions of Section 3700 of the.Labor
Code;1 shall forthwith comply with those provisions.
Date: Applicant '
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shalj'subject an employer to criminal penalties and civil fines up to $100,000; in
addition to the dost of compensation, damages as provided for in Section -3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is:h'ereby 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.an. d•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 l 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
PERMIT #
BUILDING PERMIT
0208-092
DATE VALUATION $14,877.00 LOT TRACT
JOB SITE
ADDRESS BLDG. 17 PEBBLE BEACH .30
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
PGA WEST RESIDENTIAL HOMEOWNER'S
E WESTERN PACIFIC ROOFING
PO BOX 1060
3462 LA CANIPANA WAY
LAQUINTA CA 92253
PALIVI SPRINGS CA 92262
(760)416-5877 CB1.4 4293
USE OF PERMIT
�.. GFS AT :BUILDING
DING
BLDG. 17; 80.504, 80-512,.80.520, 80.528:...'RE-ROOF WITH
POLIsURETH� 1vE FOA1V ,&ACRYLIC COATING ROOFINO SYSTEM
VALUATIgNe 14,877,00LS
ESIMATED COST OF_ CONSTRUCTION
14,877:00
PERMIT FEE SUMMARY
REROOF FEE 101-000-418-000 �30,0Q
SUB -TOTAL CONSTRUCTION AND PLAN C ECK
$30.00
LESS,PRE-PAM FEES
$0.00
TOTAL PERMIT FEES DUE NOW
$_30:00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR