0208-093 (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 8 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 1131103
Date Signature of Contracto
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that l 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
cohtractors'to `construct"the p'roj'ect' (Sec.' 704.4 'BLsihes ,'--e-Professionals
Code).
O I am exempt under.Section " B&P.C. for this reason
Date -Signature' of Owner
WORKER'S COMPENSATION DECLARATION '
I hereby affirm under penaltyof; perjury one of .the following ,declarations:
( ),: Lhave and will mainfain.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:
( ) L- 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 sectiom need not be completed_ if the permit valuation js for $100.00'or less):
(,) I certify that in the performance of.the'work,for-whlcKthis permit is issued,
I shall not employ any person in anymanner so 'as:to tiecome 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 WorkersCompensation coverage” is unlawful and.
shall subject an employer to criminal penalties: and civil flnes.up to $100,000, in
addition to the cost of compensation 'damages.as.provided for'in Section 3706
of.ihe 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 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..
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
0208-093
DATE VALUATION $17,928.00 LOT TRACT
JOB SITE
ADDRESS BLDG. 18 PEDDLE BEACH � 53�
APN -
OWNER
CONTRACTOR / DESIGNER / EN INEER
PGA WEST RESMENTIAL HOMEOWNER'S
ASIS WESTERN PACIFIC ROOFING
PO BOX 1060
3462 LA CPZ DANA WAY
LA Q=A. CA 92253
PALM SPRINGS CA 42262
(760)416-5877 CBL# 4293
USE OF PERMIT
GENERAL BLTILDINC}
BLDO.18; 80.536, 50.544;80.552; 80.560: R&ROOF &LITH
POLYURETHANE FOAM &ACRYLIC COAT ►NO ROOFIINQ SYSTEM
VALUATION .. 17,928.00 LS
ESM- 1ATED COST OF CONSTRUCTION
17,928.00
PERWi r -FEE SUMMARY '
REROOF FEE 1'01--0-00-418.-'000 $34.00
SUB -TOTAL CONSTRUCTION AND PLAN CHECK.
$30.00
LESS PRE -PAID FEES
$0.00
TOTAL PERAGT FEES DiTE NOW
$30,00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR