0202-277 (MISC)LICENSED CONTRACTOR DECLARATION
BUILDING PERMIT PERMIT
I hereby affirm under penalty of perjury that I am licensed under provisions of
with Section 7000) of Division 3 of the Business and
0202-277 TRACT
DATE VALUATION �QT
Chapter 9 (commencinq
Professionals Code, and my License is in full force and effect.
$20,0W.00
JOB SITE
ADDRESS SHOAL. CREEK 5 �_ a,3
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Cy
Lic. ClExp. Date
License # ass
3/31/03
733152 B
OWNER
CONTRACTOR / DESIGNER / EN (NEER
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Date Signature of Contractor
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OWNER-BUILDER DECLARATION
PGA WEST RESIDENTIAL ASSN.
DEL MAR PACIFIC GENERAL CONTRA
2533 SOUTH COAST HIGHWAY STE. 250
111 W I
hereby affirm under penalty of perjury that I am exempt from the Contractor's
P.O.BOX 1060
CA 92253
CARDIFF BY THE SEA CA 92007
a
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License Law for the following reason:
I, as owner of the property, or my employees with wages as their sole
LA QUINTA
(760)564-9500 CBL# 5823
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compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
USE OF PERMIT
( ) I, as owner ofthe property, am exclusively contracting with licensed
ISIS CE T ANF•OUS
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
BUILDINO 13. 54.635 54�rr54.611 54.599 • VOLUNTARY
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( ) I am exempt under Section B&P.C. for this reason
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STRUCTURAL MODIFICATIONS
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Date Signature of Owner
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WORKER'S COMPENSATION DECLARATION
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I hereby affirm under penalty of perjury one of the following declarations:
I have will maintain a certificate of consent to self-insure for workers'
VALUATION 20,000.00 L3
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W LL
( ) and
compensation, as provided for by Section 3700 of the Labor Code, for the
Operformance
of the work for which this permit is issued.
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( ) 1 have and will maintain workers' compensation insurance, as required by
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Section 3700 of the Labor Code, for the performance of the work for which this
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permit is issued. My workers' compensation insurance carrier & policy no. are:
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Cartier Policy No. 04601UNIT0009415
STATE FUND
ESTIMATED COST OF CONSTRUCTION
20,000.00
Cb a
PERMIT FEE SUh 4iARY
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(This section need not be completed if the permit valuation is for $100.00 or less).
this is issued,
CONSTRUCTION FEE 101.000-418-000 5207.00
( ) I certify that in the performance of the work for which permit
I shall not employ any person in any manner so as. to become subject to the
STRONf3 MOTION FEE • RESID 101-000-241-000 $.00
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
3
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
SUB-TOTAL CONSTRUCTION AND PLAN CHECK
$209.00
whose request and for whose benefit work is performed under or pursuant to
LESS PREPAID FEES
$0.00
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.
$200.00
2. Any permit issued as a result of this application becomes null and void if
TOTAL PERMIT FEES DUE NOW
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.
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.RECEIPT
DATE
BY
DAT FI �ED� INSPECTOR
Signature (Owner/Agent) Date