0206-072 (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
Profgs .prials Code, and my License is In full force and effect.
License # Lic. Class Exp. Date
.733553 B HIC 3/31/01
a
Date Signature of Contractor .
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury -that.) 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, Business & 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
Date. Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
() I 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 by.
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. 1>VG31Z08185 .
(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 California, and agree that if 1 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 condltlons 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 Quints, 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 cessatir1vfwork 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
..BUILDING PERMIT PERMIT# _-�-_,------------ ___
0206-072
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS BLDG. 3 TANGLEWOOD S LjL. &0 1
APN - -
OWNER
CONTRACTOR / DESIGNER /.EN (NEER
FGA WEST RESIDENTIAL, HOMEOWNERS
S WERMERS MULTI -FAMILY CORP
P.O. BOX 1060
5080 SHORHAM PLACE #105
LA QUINTA CA 92253
SAN DIEGO CA 92122
(858)535-1475 CBL# 5023
USE OF PERMIT'
GMMRAL BUILDING
SEISMIC RETRO -FIT; BLDO. 3: 54-59%54.599,54-595,
54-601,54-607,54-613. 54-619, 54-625
' VALUATION 606000.00 LS
ESTIIVIATED COSI' OF CONSTRUCTION
60,000.00
PERATIT FEE SQND4"Y
CONSTRUCTION FEE 101-000-418-000 $459.50
STRONG MOTION FEE - RESID 101-000-241-000 $li.QO
SUB TOTAL CONSTRUCTION AND PLAN CHECK
$465.50
LESS PRE -PAID FEES
$0.00
TOTAL PERAUT FEES DUE NOW
$465.50
r
RECEIPT
DATE
BY
DATE FINALED
-INSPECTOR
Project < Rex0 .J k l6 f4 6 z --
Project
Edward W. Farnsworth - - -
Job No.
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