HomeMy WebLinkAbout_SOLR22-0959_8-19-22 - Pickup Declaration
CITY OF PALM DESERT
Department of Building & Safety
73-510 Fred Waring Drive
Palm Desert, CA 92260
TEL: 760-776-6420 EMAIL: building@cityofpalmdesert.org
CONTRACTOR DECLARATION CONTRACTOR LIC#:_________________ PERMIT#:_________________
______ 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 Professions Code, and my license is in full force and effect.
Worker’s Compensation Declaration:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($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.
I hereby affirm under the penalty of perjury ONE of the following declarations (SELECT ONE):
OWNER BUILDER DECLARATION PERMIT#:___________________
______ I have and will maintain a certificate of consent to self-insure for workers' compensation, issued by the Director of Industrial
Relations as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit 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 and policy number are:
______ 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 the workers'
compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions.
DATE:________________ PRINT NAME:_______________________________ SIGNATURE:____________________________________
______ I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the reason(s) indicated
below by the checkmark(s) I have placed next to the applicable item(s) Section 7031.5 Business and Professions Code: Any city or
county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to issuance, also requires the
applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors' State License
Law(Chapter 9(commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt and the
basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).)
______ 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 and Professions Code: The Contractors' State License Law does not apply to an
owner of property who builds or improves the property, provided that the improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the Owner-Builder will have the burden of proving that it
was not built or improved for the purpose of sale.)
______ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who
contracts for such projects with a licensed contractor pursuant to the Contractors' State License Law.)
______ I am exempt from Licensure under the Contractors' State License Law for the following reason:
DATE:________________ PRINT NAME:_______________________________ SIGNATURE:____________________________________