0206-070 (BLDG)V)
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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 # Lic. Class Exp: Date.
733553 B HIC - 3.131101
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, willt do the work, and the structure is not intended or offered for
sale (Sec: 1044, Business & Professionals Code)..
( ) I, .as owner of the property, am exclusively contracting with licensed-
contractors to construct the project (Sec. 704.4, Business. & Professionals
Code).
( ) I am exempt under Section , B&RC. for this reason
Date Signature of, .Owner
WORKER'S COMPENSATION DECLARATION
1, hereby.affirm under penalty of perjury one of the following declarations:
(J 1 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
,Sgction 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:
Camey LEGION INS. CO. Policy No. WC31208185
(This section need not be completed R 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 Califomia; 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
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, 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.
Signature,.(Ow9gT46gent)_„_____ Date .
BUILDING PERMIT PERM Tit
020b-070
DATE VALUATION LOT TRACT
sw.ow.QO,
JOB SITE
ADDRESS DLDG. I TANGLEWooD 54
APN
OWNER
CONTRACTOR / DESIGNERf_EN INEER
PGA WEST RESIDENTIAL HOIVlE_ OWNERS
S WERI.AER3 MULTI -FAMILY CORP
P.O. BOX 1060
5080 SHORHAM PLACE #105
LA QUINTA CA 92253
SAN DIEGO CA 92122
(858)5352-1475 CBL# 5023
USE OF PERMIT '
GENERAL: BUILDING
SEISMIC RETRO -FIT; BLDQ. 1: 54.46% 54469,5447t
54-481.54-487.54-493, 54-499, N -SOS ,
VALUATION 64000.00 LS
ESTIMATED COST OF CONSTRUCTION
1.150,000.00
PERMIT FEE SUMMARY
- ..
CONSTRUCTION FEE' 101.000-418-000 $459.50
STRONG MOTION IEEE - RESID 101-000=241-000 $6.00
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$465.$0
IaE83 PRE -PAID FEES;
$0.00
TOTAL PERMIT FEES DUE NOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR