0206-070 (BLDG)LICENSED CONTRACTOR DECLARATION
I'hereby affirm under penalty of perjury that lain licensed under provisions of
Ghapter 9 (commencing with Section 7000) of Division 3 of the Business and
N U) Professionals Code, and my License is in full force and effect.iijj_
C 3"ch License # Uc. Class Exp. Date
733553 B HIC 3131101
�W�' -
no Z; Date Signature of Contractor !
� O: .
ti H. c OWNER -BUILDER DECLARATION
W. W ~. I hereby affirm under penalty of perjury that I am exempt from the Contractor's
a`. 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
s - Code).
( ) I am exempt under Section , B&P.C. for this reason
r . Date Signature of Owner
a Z WORKER'S COMPENSATION DECLARATION .
I hereby affirm under penalty of perjury one of.the following declarations:
r'Fa O O 1 have and will maintain a certificate of consent to self -insure for workers'
X.W L -L compensation,: as provided for by Section 3.700 of the Labor Code,. for the
O: Q performance of the work for which this permit is Issued.
Co 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
CL = H permit is issued. fury -workers' compensation insurance caller & policy no. are:
Z Carrier LEMON INS. CO. Policy No. WC31208185
i z g (This section need not be completed it the permit valuation is for $100.00 or less).
O I certify that in the performance of the work-forwhich this permit is issued,
1 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
3 Code, I shall forthwith comply with those provisions.
Date: Applicant
Waming: 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 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..
reg 4 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, Indemnity
& holdharmless the City of La Quinta, its officers, agents and employees.
2. Any permit Issued as a result of this application becomes null and. vold if
i :• 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.
Sianatura MwnAdAnantl Date
BUILDING PERMIT PERMIT#
020"70
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS BLDG. I TANGLEWOOD ��= X75
APN _ -
OWNER
CONTRACTOR/ DESIGNER*EN INEER
PGA WEST RES MMOL HOMEOWNERS
$ VVERLIER3 MUL11-FAMILY CORP
P.O. BOX 1060
5080 9HORHAM PLACE #105
LA QUINTA - CA 92253
SAAi DIEGO . CA 92122
(858)535.1475 CBL# 5023
USE OF PERMIT
G>+ ER AT • B0LDING
SEISMIC RETRO -FIT; BLDQ. 1: 54.463, 54.469, 5405,'
34481, 54487, 34493, 54499,54-405
VALUATION 60,000.001.$
ESTIMATED COST OF CONSTRIICITON
60,000.00
PERMTT FEE SOMMARY
CONSTRUCTION FEE- 101-000-418-000 5439.50
'
STRONG MOTION IEEE - RESID 101-000-241-000
SUB TOTAL CONSTRUCTION AND PIAN CHECK
$465.50
LESS PRE -PAID FM,
$0.00
TOTAL PERNIIT FEES DUE NOW -
$465.50
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR