0206-071 (BLDG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of pe jury that I am licensed under provisions of
Fes— Chapter W(commencing with Section 7000) of, Division 3 of the Business and
i14W Professionals Code, and my License Is in full force and effect.
C License # Lic. Class Exp: Date
LU n 733553 B IRC 3/31/Ol
c Z Date Signature of Contractor
OWNER -BUILDER DECLARATION
HWI hereby affirm under penalty of perjury that I am exempt from the Contractor's
CO)License Law for the following reason:
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, flusiness & Professionals Code).
( ): I, as owner of the property, am exclusively contracting with licensed
contractors to construct the .project (Sec. 7044, Business & Professionals
Code).
() I_ am exempt under Section B&P.C. for this reason
N Date ------Signature of Owner
ON..._.
0
d Q WORKER'S COMPENSATION DECLARATION
Q. I hereby affirm Under penalty of perjury one of the following declarations:
r I . O . () 1 have and will maintain a certificate of consent to self -insure for workers'
X Lu LL compensation, as provided for' by Section 3700 of the Labor" Code, for the
O J Q performance of. the work for which this permit is issued.
m Q U () I have and will maintain workers' compensation insurance, as required YM
Q U Q Section 3700 'of the Labor Code, for the performance of the work for which this
d � H pemtit is issued. My workers'"compensation insurance carrier &policy no.'are:
Z parrier LEGION INS. CO... Policy"No. WC31208185
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(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,
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
3 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, 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 commepced within 180 days from date of issuance of such
permit, or cessapo6 tf 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
020"71 .
DATE VALUATION LOT TRACT
,
JOB SITE Q
ADDRESS BLDG. 2 TANGLEWOOD
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
PGA WEST RESIDENTIAL HOMEOWNERS
QlS WERMERS MULTI -FAMILY CORP
P.O. BOX 1060
5080 SHORHAM PLACE #105
LA QUWTA CA 92253
SAN DIEGO : CA 92122
(858)535-.1475 CBL4 5023
USE OF PERMIT
GENERAL BUILDING "
SEISMIC RETRO -FIT; BLDG. 2: 54.523, 54.529, 54.535,
34-34I, 54-347, 34-553, 34-359.54-565 '
VALUATION 60,000.00 LS
ESTIMATED COST OF CONSTRUCTION
60,000.00
PERMIT FEE SU34MARY
CONSTRUCTION FEE 101-000.418.000 5459.50
:. •t
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 PERMIT FEES DUE NOW
S465.50
RECEIPT
DATEBY
DATE FINALED
INSPECTOR