0202-281 (MISC)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
N Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
U) Professionals Code, and my License Is in full force and effect.
LU
=) ch License N Lic, Class Exp. Date
Cy 7
1O
WL ti 733152 B 3131/03
Z ti Date - Signature of Contractor-
OWNER-BUILDERDECLARATION
WI hereby affirm under penalty of perjury that I am exempt from the Contractor's
f1 License Law for the following reason:
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, 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
LON
Date Signature of Owner
O rn
s WORKER'S COMPENSATION DECLARATION
CL
1 hereby affirm under penalty of perjury one of the fallowing declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
W LL compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
Q U ( } I have and will maintain workers' compensation insurance, as required by
U Section 3700 of the Labor Code, for the performance of the work for which this
MU') permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Carrier Policy No.
00 5 STATE FUND 04601UNIT0009415
r- C3
(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 became subject to the
workers' compensation laws of California, and agree that if I should become
3 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 civll fines up to $100,000, in
addition t0 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
& 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.
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
DATE
JOB SITE
BUILDING PERMIT
VALUATION LOT
1 1'1'1 f 1
ADDRESS SHOAL CREEK 54-4)?
OWNER
PGA WEST RESIDENTIAL. ASSN.
P,O,BOX .1060
LAQUINTA CA 92253
USE OF PERMIT
M;SCE LANEOUS
PERMIT a
OM -281 TRACT
CONTRACTOR/DESIGNER/
DEI. MAR PACIFIC GENERAL CONTRACT04
1
2533 SOUTH COAST HIGHWAY SIE. 250
CARDIFF BY THE SEA CA 92007
(760)564-9500 CBL4 5823
BUILDING 17. 54.443, 54.431, 54.419, 54.467 -VOLUNTARY
STRUCTURAL MODIFICATIONS
VALUATION 20,000.00 LS
ESTIIVi = COST OF CONSTRUCTION
PERMTT FEE SUMMARY
CONSTRUCTION FEE 101-000-418-000 $207,00
STRONG MOTION FEE. RESID 101-000-241-000 $2.00
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
LESS PRE -PAID FEES
TOTAL PERMIT FEES DUE NOW
RECEIPT DATE BY DATE FINALED INSPECTOR
$209.00
$0.00
$2.09.00