HomeMy WebLinkAboutWTRH20-0036CITY OF PALM DESERT
r'=�^� Department of
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�"����1 Building & Safety 73-
��' 510 Fred Waring
� - Drive
Palm Dese�t, CA 92260
TEL: 760-776-6420 EMAIL: bui4dinaCrDcitvofqalmdese�t.ora
CONTRACTOR DECLARATION CONTRACTOR LIC#: 686310 PERMIT#:
aI Hereby affirm under penaity 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.
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Worker's Comnensation Declaration: ,��'��4' � �'�LV1 �'� ��C' ' "yS " � � \, �
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 herebv affirm under the penaltv of periury ONE of the followinR declarations (SELECT ONE�:
❑I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by the Director of Industrial
Relations as provided by Section 3700 of the Labor Code, for the performance of the work for which this permit is 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
Csubject 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: ��4IZOLO PR,NrNAME: ASHLEY MCDONALD SIGNATUR . �
OWNER BUILDER DECLARATION PERMIT#:
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 p�rsuant 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 subje:ts 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: 7he 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:
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City of Palm Desert
Department of Building and Safety
Building Permit Application
(For Office Use Only)
PERMIT NO:
PLAN LOCATION:
APN:
Project Address: 40945 AVENIDA CALAFIA PALM DESERT CA 92260 Suite #
Total Value of work: $ 2,200.00
Project Description (be specific):
(1) 50 GALLON WATER HEATER C/O IN SAME LOCATION (WATER HEATER ONLY)
Contractor Business Name Property Owner Name
GENERAL AIR CONDITIONING & PLUMBING WAYNE TYLER
Address 31170 RESERVE DRIVE Address 40945 AVENIDA CALAFIA
c�ty THOUSAND PALMS Z�p CA 92276 c�ty PALM DESERT Z�p CA 92260
Phone �760) 343-7488 Phone �619) 788-1739
E-mail E-mail
Contractor �icense No. 686310
❑Architect Name ❑Designer Name Engineer Name
Address Address
City Zip City Zip
Phone Phone
E-mail E-mail
License No. License No.
Applicant Name Signature Date
CHARLIE PARK �� 07/24/2020
Contact Telephone Number E-Mail
818-735-7876 CHARLIE@IPERMITCA.COM
*THE REVERSE SIDE MUST BE COMPLETED FOR RESIDENTIAL REMODELS AND TENANT IMPROVEMENTS
73-510 Fred Waring Drive, Palm Desert, CA 92260 •(760) 776-6420 • www.cityofpalmdesert.org