0208-038 (RR)LICENSED CONTRACTORDECLARATION
I hereby.affirm under penalty of perjury that 1 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 1/31110,12
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 own ner;;of the property, or my employees with wages as their sole
compensation, will do'the work:, and the structure isnot intended or,offered for
sale (Sea 7044, Business & Professionals Code).
( )
'I,. as owner 'of the property; am. 'ex clusively contracting .with licensed
contractors to construct , the project (Sec. 7.044, Business '& Professionals
..Code). s
'O-am,exempt under Section, j B&P.C. for this reason
Date Signature `of Owner'
WORKER'S:COMPENSATION DECLARATION''-
. � .. .. _.
I hereby affirm under;Apenalty of ,perjury one of the following declarations:
O I have and;will maintain a certificate of consent -to self -insure for,workers'
compensation, as provided :for by Section=3700 of ''the Labbr Code, for the
performance of the work,for Which this permit is issued.
( ) I have and`wilF maintain workerscompensation insurance, as,required ;by
Sectlon'3700 of the Labor Code,;foi the"performance-of..the work for which this
perm' is, Issued.:My workers `compensation insurance carrier:& policy.no*are:
Gainer STATE FUNLti `` 'Policy No. '0457624-02
'ao-(This.sectlon need not be completed -if ;the. pemiit valuation is"for $100.00 or less).
( ) I certify that In the performance of the work for which this permit is issuetl,,
.1 .shall not.employ any person in any manner so ,as to �become'subject to, the
.wo'rkers ; compensation laws. of Callfomia, _and ;agree that if I should become
subjectto the workers,:corripensation-provisions of Section 3700 of the Labor
Code, I shalhforthwlth comply with those provisions.
..: ,
..:Date: Applicant—
Warning :`Fail Ore
pplicantWarning:`FailOre to.secure Workers' Compensation?coverage , is unlawful and
shall subject an employer;to criminal penalties and civiCfines`up to $100,000, in
addition to the cost of compensation,,damages as provided for.in Sectiori'3706
of the Labor Code, interest=and attorney's fees. A«"
'4` imP.ORTANT --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 & eac-
h 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
PERMIT #`
-EUILfDING.'PERMIT
0208-038
DATE VALUATION-.., $16,704.00 LOT TRACT
JOB SITE
ADDRESS BLDG. 1 PEBBLE BEACH
OWNER
CONTRACTOR / DESIGNER / ENGINEER
PG.A: WEST RE_ SMENTIAL HOMEOWNER'S
.S2 WESTERN PACIFIC ROOFING
PCS BOX 106Ct
3462 LA CANMA1,TA WAY
-LA QUIN'TA CA 922531
PALM SPRINGS CA 92262
(760)416-5877 CBL4 4293
USE OF PERMIT
GENERAL BUILL)ING
80.555,"80.563; 80.`571, 90-379:'°` RE.ROOF WITH .
BLDG. IJ
POLY-tiRE— A . ETOAM &ACRifLic C0ATFHG R.00FiN0 SYSTEM
VALUATION. 16;704, (10I I.S
6
- ESTIMATED COST OF -CONSTRUCTION
.:r. 16,704.00
P_ ERAGT FEE StTM ARYt
.
REROOF FEE. 101-00b-418-000 $30.00
SUB -TOTAL CONSTRUCTION PND PLAN CIIECK
$30.00
LESS PRE -PAID FEES
$0.00
TOTAL PERMIT FEES DUE NOW
$30.00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR