0208-077 (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 HRC 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 iproject (Sec: 7044; Business & Professionals,
Code).
O I am exempt under Secfion 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: .
O I
ave and wiilf.;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 tkie 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 s compensation insurance carrier &policy: no: are:
Carrier STATE FUND 'Policy No. 0457624,03
(This section need,not.be completed if the permif valuation is for $100.00 or less),-.'
O I certify.that in'the performance of the work for which this permit is issued,
I shall not erriploy'any.person in any manner sous to become subject to the .
workers' compensation laws of California,•and agree that if I should become
subject to the; workerscompensation provisions of Section 3700 of the Labor
Code, I shall foithwithComply with those provisions. -
Date: Applicant
.Warning: Failureto secure Workers' Compensation. coverage is unlawful and`
shallaubject 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 attomey's fees.-
IMPORTANT
ees.IMPORTANT Application ivhereby 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 resultof 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#
0208-077
DATE VALUATION $17,928.00 LOT TRACT
JOB SITE
ADDRESS ]BLDG. 2 PESELE 13EACH $ D -53,7
APN
- -
OWNER
CONTRACTOR / DESIGNER / EN (NEER
PGA WEST RESMENTIh,L HOIVMOWNERIS
: WESTERN PACIFIC ROOFING
PO BOX 1060
3462 LA CAMPANA WAY
LACUINTrCA92253
rgS a n.n n r n
PALMSPRINGS rh `ILLOL
(760)416-5877 CRL# 4293
USE OF PERMIT
GENERAL B1 DING
BLDG. 2; 80.523, 80.531, 80.539, 80.547: RE•ROOF VnTH
POLYURETHANE FOAM&ACRYLIC COATING ROOFING SYSTEM
VALUATION 17,928.00 LS
ESTEMATED COST OF, CONSTRUCTION
17,928.00
PERNRT FEE SUA4M iRY
REROOF FEE` 101-000415-000
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$30.00
LESS PRE=PAID FEES
$0.00
TOTAL PERTT a= FEES D[TE NOW
$30.00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR