0208-093 (RR)LICENSED CONTRACTOR DECLARATION
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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
235717 C-39 B HIC 1/31/03
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:
( ) 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 co6tracting with licensed
contractors»+to construct -the-1 project (Sec. 7044•,- Business & Professionals
Code)
O 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:
(.)
have and will maintain a ce'rtlflcate..of consent to, self, insure fors workers'
compensation, as provided for•'by Section 3700 of. the Labor Code', for the.
performance of.the work.foi which -this permit is issued..
L have :and will maintainworker' ' 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. ''STATE.FUNL?c. Policy . 0. y ::D45762442
I.
(THis.section need not be completed if the pennitvaluatlonis f04$ 0.0.60 or less).
O I certify that in the performance of'the work`for which this permit is issued,
:1 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 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.fee&
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; indemnity
& 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
BUILDING PERMIT PERMIT#
0208-093
LOT TRACT
'DATE VALUATION $17,928.00
JOB SITE
ADDRESS IBLDG.18 PEDDLE ]BEACH
APN - -
OWNER
CONTRACTOR / DESIGNER IEN (NEER
PGA WEST RESIDENTIAL HOMEOWNER'S
kS,c WESTERN PACIFIC ROOFING
PO BOX 1060
3462 LA CAIvIPANA WAY
LA QUANTA CA 92253
PALM SPRINGS CA 92262
(7601416.5877 CBL9 4293
USE OF PERMIT
GENERAL BUILDING
BL170.IS; 80.536, 50-5441 8O.552, 80.560: RE -ROOF WITH .
POLYURETHANE FOAM &ACRYLIC COATFRO ROOFING SYSTEM
VALUATION 17,928,00 LS '
-EST_1MATED COST OF CONSTRUCTION..
•T7,928AU•
PERMIT FEE SUMMARY
REROOF FEE 101-000-418-000 530.00
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$30.00
LESS PRE -PAID FEES.
$0,00
TOTAL PERMIT FEES DUE NOW
$30.00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR ,