0212-139 (MISC)LICENSED CONTRACTOR DECLARATION
N I 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
W Professionals Code,. and my License is in full force and effect. Exp. Date
Lic. Class
License # 02/29/2(
`n 774382 B C33 HIC
Date ---- Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I 'am exempt from the Contractor's
License Law for the following reason: employees with wages as their sole
( ) I, as owner of the property, or my
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 Is
contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). B&P.C. for this reason _—
( ) I am exempt under Section
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.
( ) I 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:
Cartier STATE FUND Policy No. 468784
(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 I should become
subject to.tFie 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.
BUILDING PERMIT 0h2439 TRACT
DATE VALUATION LOT
.A nOn=
$4,5=310
1�APN
JOB SITE 7
ADDRESSCOED FOOT y 3 (�
` BLDC3: 6 WII'�
CONTRACTOR/DESIGNER/EN INEER
OWNER
PGA WEST RE-SIDENTIAL HOA EPOCH CONSTRUCTION, INC.
42-600 CAROLINE COURT 7062 CONVOY COURT CA 92111
PALM DESERT CA 92211 SAN DIEGO
(858)560-0698,
USE OF PERMIT
GM4ERALBUMDIRG
BLDG. 6: 15.341, 35.313, 55-3.65.'REPAIR HANDRAILS & DECK
COATING
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
& hold harmless the City of La Ouinta, its officers, agents and employees.
a 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.
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
VALUATION
4,500.00 LS
ESI'11VlATED COST OF CONSTRUCTION.
4,500.00
PERMIT FEE SUMMARY 101-000-418-000 (30.00
CONSTRUCTION FEE
$30.00
LA14 CHEM
LE
SUB -TOTAL CONSTRUCTION AND9 PRE -PAID FEES SO=
TOTAL PERMIT FRES DUE NOW x'00
DATE I BY
E FINALED INS'