HomeMy WebLinkAbout-0033CITY OF PA�M DESERT
��•� Department of Building & Safety
/' r `..._""�,
.� � � ��` i3-510 Fred Waring Drive
=��� �� Palm Desert, CA 9226p
TEL: 760-?76-642Q EMAII.: b��6dis�� r�a��c�f����ad����.�ra�
COJr�� ACTOR DEC�ARATION CONTRACTOR LIC#:,,_, �7�-�7 ��O PERMMT#: �5�� ZC1'CJCJ?,�
�.��y affirm under penalty of perjury that I am licensed under provisions of Chapter 9(commencing with Sectian ?OOOj of
Division 3 af the Business and Professians Code, and my license is in full farce and effect.
Worker's Compensation Declaratian:
WARfVING: FAILURE TO SECURE WpRKERS' GOIUIPENSATION COVERAGE IS UNLAWFUL AND SHALL 5UBJECT AN EMPLOYER TO CRIMINAL
PENALTIES AND CIVIL FINE5 UP TO QNE HUNDRED 7HOU5AND DOLI.ARS {$1q0,000), IN ADDITION 70 THE CQST OF COMPENSATION
DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND AITORNEY'S FEES.
I herebv aifirm under the penaltv of perjury ONE af the fallawin� declarations (SELECT ONEj:
I have and will maintain a certificate of consent to self-insure for workers' compensation, issued by the Director af Industrial
Relations as provided for by Section 3700 af the Labor Code, for the perfarrnance af the work for which this permit issued.
�� 1 have and will maintain workers' compensation insurance, as required by 5ection 370p af the Labor Code, forthe performance
of the work for which this permit is issued. My workers' compensation insurance carrier and palicy nurnber are;
i certify that in the performance of the work for whith this permit is issued, I shall not emplay any person in any manner so as
to become subject to the workers' compensation laws of California and agree that if i auld become s bject to the workers'
compensati n pr visians of Section 3700 af the labor Code, 1 shall forthwith comply with t os pravisians.
DATE: � � PRINT NAME:,,_, .FJV �1�� �/ /�i' C�'�+ 51GNATUR :
OWNER BUILDER DECLARATIOfV PERMIT#:
I hereby affirm under penalty of perjury that I arn exempt fram the Contractors` State License Law for the reason(s} indicated
below by the checkmark(s) I have placed next to the applicable item(s) 5ection 7031.5 Business and Professions Code: Any city or
county which requires a permit to construct, a(ter, improve, demalish, or repair any structure, priar ta issuance, alsa requires the
appiicant far the permit to file a signed statement that he or she is licensed pursuant to the pravisions of the Contractors' State License
I.aw{Chapter 9(cammencing with Section 7000) af 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 af
not mare than five hundred dallars ($5p0).)
I, as awner of the property, or my employees with wages as their sole compensatian, will do the work, and the structure is
not intended or offered for sale (Sec. 7044, Business and Professions Code: 7he Cantractars' State �icense Law does not apply ta an
owner of property who builds or improves the property, pravided that the improvements are not inYended ar offered for sale. (f,
however, the buiiding or improvement is sold within one year of completion, the Owner-Builder will have the burden of proving that it
was not built or impraved for the purpose of saie.)
i, as owner of the properYy, am exclusively contracting with licensed contractors to canstruct the project (Sec. 7p44, Business
and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or irnproves thereon, and who
contracts for such projects with a licensed contractar pursuant to the Contractors' State License Law.)
I am exempt from Licensure under the Contractars' State License �aw for the follawing reason;
DATE: PRINT NAME: SIGNA7URE