0206-070 (BLDG)LICENSED CONTRACTOR DECLARATION
HI hereby affirm under penalty of perjury that I am licensed under provisions of
r Chapter.9 (commencing with Section 7000) of Division 3 of the Business and
'N LOU).', Professionals Code, and my License is in full force and effect:
•.
C �_ License # Lic. Class Exp. Date.
' W T_ 733553 B HIC3/31101
A' Z r� Date Signature of Contractor
CD Q, I
F- j= �. OWNER -BUILDER DECLARATION
J(>.�
WW I hereby affirm under penalty of perjury that I am exempt from. the Contractor's
a' License Law for the following reason:. .
a 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).
�!� O I am exempt under Section . , B&RC. for this reason
c'nu0. . Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
a" z
o. c I hereby affirm under penalty of perjury one of.the following declarations:
Fa-. p. (.) 1 have and will maintain a certificate of consent to self -insure for workers'
X 111 L� compensation; as provided for by Section 3700 of the Labor. Code,. for the
Or performance of the work for which this permit 'is issued.
I have and Will maintain workers' compensation insurance, as required by
QU" Q Section 3700 of the Labor Code, for. the performance of the work for which this
.
Ll-t�''1-- permit is issued. My -workers' compensation insurance carrier & policy no. are:
Z' Carrier LEMON INS. CO,Policy No. WC31208185
! co, 5
t t (This section need not be completed if the permit valuation is for $100.00 or less).
- O I certify that in the performance of the work for which this permit•is issued,
s 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 l should become.
? subject to the workers' compensation provisions of Section 3700 of the Labor
3 `r Code, 1 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
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
;,.f 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
r whose request and for whose benefit work is performed. under or pursuant, to
any permit issued asa result of this applicaton agrees to, & shall, indemnity
& 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.
Signs _ Ow
}�::�•: _. 9 _ (ner/Agent)......_ --- -- _. Date
BUILDING PERMIT PERMT/t
0?.Q6-070
DATE VALUATION'�'� LOT TRACT
JOB SITE
ADDRESS BLDG. I TA1�GI"OOn 9 9
APN
- -
OWNER
CONTRACTOR /DESIGNER4.EN (NEER
PGA WEST RESIDENTIAI, HONIEOWNEM
kSS W..ERMEEM MULTI -FAMILY CORP
P.O. BOX 1060
5080 0HORHAM PLACE #105
LA QU1NTA CA 42253
SAN DIEGO CA 92122
(858)535.=1475 CBL,# 5023
USE OF PERMIT '
GENERAL BUILDING
SEISMIC RETRO -FIT; BLDO. 1: 54463,54469,5447%
34-481.54-4 S4493,54499,54--505
VALUATION 606000.00 LS
ESTD&4TED COST OF CONSTRUMON
60.000.00
PERma FEE SU1�7ARY
_ _.
- CONSTRUCTION F'EE' 101=000-418-000 $459.50
STRONG MOTION FEE, RESID° 101-000441-000 $6.00
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$465..50
LESS PRE -PAID FEES:.4
$0.00
TOTAL PER?vffr FEES DUE NOW
$465.50
RECEIPT
DATE
BY
DATE FINALED •
INSPECTOR