0206-073 (BLDG)LICENSED CONTRACTOR DECLARATION
Cf) 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
Lu. , Professionals Code, and my License is in full force and effect.
p 5 M License # Lic. Class Exp. Date
w733553 BHIC 3/3}/0}
yr Z r.. Date Signature of Contractor
WOWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury. that I am exempt from the Contractor's
Cr) License Law for the. following reason:
Z ( ) 1, 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).
LO
( ) I am exempt under Section , B&P.C. for this reason
CM Date Signature of Owner
drn
< WORKER'S COMPENSATION DECLARATION
ro Q 1 hereby affirm under penalty of perjury one of the following declarations:
F- O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w � compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q U ( ) I have and will maintain workers' compensation insurance, as required bye's
O Q Section 3700 'of the Labor Code, for the performance of the work for which this
a 0 Z permit is issued. My workers'. compensation insurance carrier .policy rio. are:
Caner .-LEGION INS. ea Policy No. Wc31208185
g (This section need not be completed if the permit valuation is for $100.00 or fess).
() 1 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 it 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
A 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 cessation of work for 180 days will subject permit to cancellation.
r
1 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#
DATE.. -VALUATION, �4�+�000.� LOT.,. TRACT
wF�+
JOB SITE
ADDRESS BLDG. 4 TANC�LEWOOD ��[_ 6 7 J�
APN
_
OWNER
CONTRACTOR/DESIGNER/EN (NEER
PGA WEST AESIDENTIAL HOMEOWNERS
S WERMERS MULTI -FAMILY CORP
P.O. BOX 1060
5080 SHORHAM,PLACE #105
Lei QUIrNTA CA 92253
SART DIEGO CA. 92122
(858)535-1475 CBL# 5023
USE OF PERMIT
GENERAL BUII DING
SEISIMIC RETRO -PTT; BLDG 4: 54-643,54-649,54-655,
54-661, 54-665, 54-6A 54-654,.34-685
' VALUATION 6'000.00 LS
ESTIMATED COST OF CONSTRUMON
60,000.00
PERMIT FEE SUMMARY'
CONSTRUCTION FEE 101-000-418-000 E459.50
STRONG IMOTION 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
$465,50
RECEIPT
DATE
BY
DATE FINALED
IN
09/29/2002 12:56 7609227556 FARNSWORTH IORO
Verbal Discusslons and/or Instructions with Contractor/Architect:
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