0206-071 (BLDG)LICENSED CONTRACTOR DECLARATION
1 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 � BMC 3/31/01
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, flusiness & 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
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
OI 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.
() 1. have and will maintain workers' compensation insurance, as required
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:
Carrier LEGION INS. CO. Policy No. WC31208135
(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,
1 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, 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
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 commepced within 180 days from date of issuance of such
permit, or cessajon'& 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
PERMIT#
BUILDING PERMIT
0206-071
DATE VALUATION M 000.E LOT TRACT
DDR B SITE SS BLDG. 2 TANG•LEIWOOD - 553
APN
OWNER
CONTRACTOR / DESIGNER / EN INEER
PGA WEST RESIDENTIAL HOMEOWNERS i
UIS WERM ERS MULTIFAMILY CORP
P.O. BOX 1060
5080 SHORHAM PLACE #105
LA QUANTA CA 92253
SAN DIEGO : CA 92122
(858)535-.1475 CBL# 5023
USE OF PERMIT
G�'�'R AT.BUIIDIATG
SEISMIC RETRO -FIT; • BLDQ. 2: 54-523,54-529,54-535,
S4441.54- 47, 54-353, 34-359, 54-56S
VALUATION 60,000.00 LS
ESTIMATED COST OF CONSTRUenoN
60,900.00 '
PERIVIIT FEE SU34KARY
CONSTRUCTION FEE 101-000-418.000 5459.50
STRONG MOTION FEE - RESID 101-000-241-000 $6.00
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$4.65.50
LESS PRE -PAID FEES
$0.00
TOTAL PERMrr FEES DUE NOW
$465.50
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR