0206-070 (BLDG)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 4 Lic, Class Exp. Date .
733553 B IHC 3131101
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),
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&RC. for this reason
Date Signature. of Owner
WORKER'S COMPENSATION DECLARATION
I hereby.affirm under penalty of perjury one of the following declarations:
(,) I have and will 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 the work for which this permit is issued.
( ) . I have and will maintain workers' compensation insurance, as required by
,Section 3700 of'the Labor Code, fora the performance of the work for which this
permit is' Issued. My -workers' compensation insurance carrier & policy no. are:
Canter LEGION INS: CO.. Policy No. WC31208185
(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 thatif'l 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
additionto the cost of compensation, damages as provided for In Section 3708:
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,
& 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 PERM T#
0205-070
DATE VALUATION LOT TRACT
JOB SITE
1�
ADDRESS BLDG. I TAGI�E`,iNOOD 5!�_ lyCB�
APN
OWNER"
CONTRACTOR / DESIGNERf EN INEER
PGA WEST RESMENTIAL HOMEOWNERS
kSS VMME.ER3 MULTI -FAMILY CORP
P.O. BOX 1060
5080 SHORHAM PLACE 4105
LA QUINTA • CA 92253
SARI DIEGO CA 92122
(858)535.14.75CBL# 5023
USE OF PERMIT '
GENERAL BUIL DING
SEISMIC RETRO -FIT; BLDO.1: 54-463,54-469,5-4-475,
54481; 34487, 54493, S4499,54 -50S'
VALUATION. 60000.00 L3
Eyrilu TED' COST OF CONSTRUCTION,
60,000.00
Plani1TFEE SUI dALARY
CONSTRUCTION FEE- 101-000-41.8-000 5459.50
STRONG MOTION AE- REBID 101-000-241-000
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$465.50
LESS PRE -PAID FEES:
$0.00
TOTAL PERhOT FEES DUE NOW
$465.x.. •.
RECEIPT,
DATE
BY
DATE FINALED
INSPECTOR