0206-070 (BLDG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business' and
co Professionals Code, and my License is In full force and effect.
=) M License # Lic. Class . Exp. Date
W 733553 E HIC 3M/01
Z r, Date Signature of Contractor
fl0,
J U OWNER -BUILDER DECLARATION
L W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
_ IL
0 License Law for the following reason:.
Z ( ) 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).
C () I am exempt under Section B&P.C. for this reason
O Date Signature of Owner
o�
a Q WORKER'S COMPENSATION DECLARATION
j Q I hereby affirm under penalty of perjury one of the following, declarations:
p () 1 have and will maintain a certificate of consent to self insure for workers'
< W U compensation, as provided for by Section 3700 of the Labor Code, for the
0 J Q performance of the work for which this permit 'is Issued.
Q U (:•.); I have and will maintain workers' compensation insurance, as required by
j U Section 3700 of the Labor Code, for the performance of the work for which this
L'•LO la— permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier LEOION INS. CO. Policy No. WC31203185'
g (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,
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
6: 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
#: I & hold harmless the City of La Quinta, its officers, agents and employees.
X 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. 1 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/Agenty--- - Date
BUILDING PERMIT PERMIT#
0206-070
DATE VALUATION %0,0w.00 LOT I TRACT
JOB SITE
ADDRESS ii BLD(, I TANGLE00D . 54— !7C 4r04F
APN
OWNER
CONTRACTOR/DESIGNER/EN INEER
PGA WEST RESIDENTIAL HOMEOVf7 MS
S WERMERS MULTI -FAMILY CORP.
P.O. BOX 1060
5080 SHORHAM PLACE #105
LA QUIpTfA CA 42253
SART DIEGO CA 92122
(858)535-1475 CBL# 5023
USE OF PERMIT
GII4E1ZAL BUI 1NG
SEISMIC RETRO -FIT; BLDG 1: 54463,,,54469,5447%
54481, 541157, 54493, 54499, A -SOS
VALUATION 606000.00 LS
ESTD4ATED COST OF CONSTRUCHON
tSQ,000.�
PERMIT FEE 9111hID11ARY
CONSTRUCTION FE# ..101-000-41.8-000. 5459.50
STRONQ MOTION FEE - RESID . 101-000-241-000 $6.00
SUB TOTAL CONSRUCTION ARID PLAN Cl=
$465.50
LE39 PRE -PAID FEES.
$0.00
TOTAL PERMIT FEES DUE NOW
&465.50
�R
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR