0206-071 (BLDG)LICENSED CONTRACTOR DECLARATION
W I hereby affirm under penalty of perjury that I am licensed under provisions of
f- Chapter 9'(commencing with Section 7000) of Division 3 of the Business and
04 W ' Professionals Code, and my License is in full force "and effect.
onm License # " Lic. Class Exp. Date
CY to .733553 B Inc 3/31/01
Z r Date Signature of Contractor
JO� _
V OWNER -BUILDER DECLARATION
W I hereby affirm under penalty of perjury that I am exempt from the Contractor's .
a. License Law for the following reason:
Z( ) 'l, "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, pusiness & Professionals Code).
( ): I, as owner of the property, am exclusively contracting with "licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) 1, am exempt under Section , B&P.C. for this reason
N Date Signature of Owner
0 C14
CL Q " WORKER'S COMPENSATION DECLARATION
IO< 2 . I hereby affirm under penalty of perjury one of the following declarations:
I—. ;p . , O 1 have. and will maintain a certificate of consent to self -insure for workers'
.X W L compensation, as provided for' by Section 3700 of the Labor. Code, for the
O J _J performance of. the work for which this permit is. issued.
CID Q U () 1 -have and will maintain workers' compensation insurance, as required IV,,
p U Q ' Section '3700 "of the Labor Code, for the performance of the work for which this
a LQl— . permit is issued. My workers'. compensation insurance carrier & policy no. ,are:
V "? " Parries: -LEGION INS. CO.` Policy No. WC31208185
.6 O
J (This section need not be completed If the permit valuation is for $100.00 or less).
( ) t certify that in the performance of the work for which this permit is issued,
shall not employ any personin any manner so as to become subject to the
workers' compensation laws o'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
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 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 cessapori.t)f 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.
jSignature (Owner/Agent) Date
PERMIT# - ---- ----..r
BUILDING PERMIT
0206-071
DATE VALUATION560owoo LOT TRACT
JOB SITE
ADDRESS BLDG.2 TAN LEWOOD SG{_SC�f
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
PGA WEST RESIDENTIAL HOMEOWNERS
OS VIER AM 14MTI-FAIQLY CORP
P.O. BOX 1060
5080 SHORHAM PLACE #105
LA QUINTA CA 92253
SAN DIEGO : CA 92122
(858)535-.1475 CB1# 5023
USE OF PERMIT
GEN RAT. BUILDING
SEISMIC RETRO -FIT;. BLDG. I: 54-5251,54-529,54.531,
54-541.54-547.54-553, 54-559, 54-565
VALUATION 60.000.00 LS
ESIMATM COST OF CONSTRUMON
60,000.00
PFIZBM FEE SUMMARY
CONSTRUCTION FEE 101-000-418-000 1459.50
STRONG MOTION FEE - RESID 101-000-241-000 $6.00
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$465.50
LESS PRE -PAID FEES
$0.00
TOTAL PERMT FEES DUE NOW
S465.50
r
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR