0206-071 (BLDG)LICENSED CONTRACTOR DECLARATION
Vj ` I hereby affirm under penalty of perjury that I am licensed under provisions of
fF— Chapter 9'(c6rnmencing with Section 7000) of Division 3 of the Business and
N W ' '' Professionals Code, and my License is in full•force and effect.
License #'- Lic. Class Exp. Date
CY
LLJ V .733553 B HIC 3/31/01
Z � Date Signature of Contractor
cc 0 !�
OWNER -BUILDER DECLARATION
HW ~ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
co
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, pusiness & Professionals Code).
( ): 1, as owner of the property, am exclusively contracting with licensed
contractors to .construct the project (Sec. 7044, Business & Professionals
Code).
CV) () 1. am exempt under Section B&P.C. for this reason
N Date Signature of Owner
CL Q WORKER'S COMPENSATION DECLARATION'
Q Q . 1 hereby affirm under penalty of perjury one of the following declarations:
r F— O O I'have and will maintain a certificate of consent to self -insure for workers'
X W u- compensation, as provided for by Section 3700 of. the Labor -Code, for the
0 _ _J performance of the work for which this permit is issued.
m Q U () 1 have and will maintain workers' compensation insurance, as required fir;
Q Q Section 3700. of the Labor Code, for the performance of the work for which -this
t] H permit is issued. Nh! workers' compensation insurance carrier & policy no..are:
11 Z Perrier LEGION INS. CO. Policy No. WC31208185
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J (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, I shall forthwith comply with those provisions.
Date: Applicant
Waining: 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 appiicaton 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 cessapon 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.
I
Signature (Owner/Agent) Date
PERMIT
BUILDING PERMIT
0206-071 .
DATE VALUATION "oo.w LOT TRACT
'
JOB SITE
ADDRESS BLDG. 2TANGLEIWOOD 5th, 54=
APN
OWNER
CONTRACTOR / DESIGNER J EN (NEER
PGA WFM RESIDEIMAL HOMEOWNERS
WS WAS MULTI -FAMILY CORP
P.O. BOX 1060
5080 SHORHAM PLACE #105
LA QUINTA CA 92253
SAN DIEGO CA 92122
(858)535-.1475 CBL6 5023
USE OF PERMIT
GENERAL. B=DING
SEISMIC RETRO -FIT;. BLDO. 2: 54-523,54-529, 54.535,
54-541.54-547, 54-553, 54-559, 54-565
VALUATION 606000.00 LS
ESTIlVIA= COST OF CONSTRUCTION
60,000.00
PEP -3M 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 PERMIT FEES DUE NOW
$46+5.50
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR