0206-070 (BLDG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that lam 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.
733553 B HIIC 31131/01
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, amexclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code)`-
( ) I am exempt under Section . 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:
() 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, for. the performance of the work for which this
'permit is issued. My -workers' compensation insurance carrier & policy no. are:
Cancer LEGION INS. CO; Policy No. WC31208185
(This section, need not be completed N 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,1 shall forthwith'complywith 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 $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. .
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his -
application.
.1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed. under or pursuant, to
any permit issued as a result of this applicaton agrees to, & shall; Indemnify
& hold. harmless the City of La Quints, its officers, agents and employees.
2, Any permit issued as a• result• of this application becomes null and void if.
work is not commenced within 180 days.from date of Issuance of such -
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify, that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature ,_(Owner/Agent)_ ._ _ _ _- Date
BUILDING PERMIT PERMT1i
0206-070
DATE VALUATION LOT TRACT
S�tf1,(tfNl,lNl '
JOB SITE
ADDRESS BLDG. I T"()1"O0D . 5,q
APN
OWNER'
CONTRACTOR /DESIGNER4.EN INEER
PGA VIEV RESIDENTIAL HOMEOWNER$
kSS WERL4M MCILTI-FAMILY CORP
P.O. BOX 1060
5080 3HORHAM PLACE 4105 -
LA QUIIaTA CA 92253
SAN DIEGO CA 92122
(858)535.-1475 CBLN 5023
USE OF PERMIT
GM4ML L.B=INf
SEISMIC RETRO -FIT; BLDQ 1: 54-463, 54.469, 54.47%
54-481.54-'487, 34493, 54499, 54-505
VALUATION 9000.00 LS
ESIMIATED COST OF CONSTRIICTION
00.E-00
PERMIT BEE 90ACAA1tY
CONSTRUCTION FE�eE- 101-000-41.8-000 $459.50
STRONG'MOTION itFLE RESID- 101-000-241-000 $6.00
3
SUB -TOTAL. CONSTRUCTION AND PLAN CHECK
$464.50
LESS PRE -PAID FEES :
$0.00
TOTAL PERNITT FEES DUE NOW
$465.50,
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR