HomeMy WebLinkAboutWIND23-0058 APPLICATION AND DECLARATION-SIGNED.pdfOFFICE USE ONLY - PERMIT NO.
PIAN LOCATIQN:
�� :�: . CITY OF PALM DESERT
;�° % ��� DEPARTMENT �F DEVELOPMENT SERV�CES
73570 �red Waring Drive, Palm E]esert, Cafi�ornia 92260
Phone (7BQj 7T8�435 ■ Fax (760) 778�392 • nermitcenter(�cit�ofaalmdesert.ora
BUILDING PERM�T APPLICATION
Praject Address; �� � Z�� � ,'""� '� '� �� �, j�.c� l ' � .,.�.e,�.�" G�° Z-. � O
Totai Value of Work $: y�'`'
Project Description (Describe the Specific Nature oi Appro�al Requested):
REROOF CRRC: HVAC SEER: WATER HEATER ENERGY:
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Cor�tractor Business Name:
Phone:
MaEling Address:
City:
State: Zip: EmaiE:
License No.
Property Owner Nam�
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Fax:
Mailing Address: Z i''tr.i Fax:
City: C w( � State: G Zip: �bEmaiL• �1`Z.�i V�S�r�� o(st ��� y[.t.Cc � j�-r
ArchitectlDesigner Name (circle ane):
Phone:
Mailing Address:
City:
License No.
State: Zip:
Fax:
Ema9l:
Engineer Name:
Phane:
Mailing Address:
city: scate
License No.
zi�:
�ax:
Email:
City:
State
Zip:
Email:
Applicant Signat�re (must match the applicant name above): By s�gning this application, I certify that the informatior�
provided is accurate. I understand that the City mighf not appro�e what I am a plying for andlor might require condiiions
of appro�al. r `�
Prirrt Name: �✓"�~ � ���� Signature. � Date: ','� ' ` S � a�
"THE REVER8E SIDE �,� BE COMPLETED FOR RE3IDENTIAL R�MODELS AND TfNAl1}T 4MPROVEMENT3
Mailir�g Adc#ress: Fax: _
PALM DESERT PERMIT CENTER
73-514 Fred Waring �rive, Palm Desert, Califomia
(780} 776-6435 permitcenter(Dcityofpalmdesert.o.r�
DECLARATION
coNr�►croR o�cu�►noN —C�NTRACTOR LIC#: PERMIi#:
❑ I Hereby affirm under penalty oi perjury that I am licensed �nder prov'rsfons of Chapter 9(commencing with Section 7000a af Division
3 of the Business and Professions Code, and my Itcense ts in full force and effect.
Worker's Comaensation [�edar�tian: WARNING: FAII.URE TO SECURE WORKERS' CQMPENSATION COVERAGE IS UNIAWFUL AN{� SHALL
SUBJECF AN EMPLOYER TO CREMINAL PENALTIES AND CML FlNES UP TO ONE HUNDRED THOUSAND DOLFARS �$100,000), IN ADDI710N
'1'Q 7HE C051' OF OOMPENSATlON DAMAGES AS PROViD�D fOR IN SC�Cf10N 3706 OF THE LABOR CODE, If+IT�FiEST, AND ATTORi11EY'S FEfS.
I hereby atfirm under penalty o� parjury aNE of the iollowin� daclaraUons (MUST CHECK ONE OF THE FOLLOWING}:
1 ha�e and will maintafn a certificate of consent to self-insure for worlcers' compensation, as provfded for by the Directar af
I ndustrial Relallons as provided by Section 3700 of the Latror Code, for the performance of the wark for which thts permit is issued.
I have and wiEl maintatn workers' compensaYion insurance, as required by Section 3700 of the Labor Code, for the perFormance of
the work for whlch this permit Es issued. My worker� compensation insurance carrier and pollcy number are:
I cerbify that in the perFormance of the work for which ihis �ermit is issued, I shail not employ any persan in any manner so as to
become subject to the Workers' Compensation Laws of California. and agree #hat if 1 should become sub]ect to the workers'
compensatfon provisions of Sectlon 3700 of the Labor Code, i shall forthwith corriply with those provisions.
Date: Print Name: Signature:
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QWN�R BUILDER D�CLARATION — PERMIT#:
�I hereby affirm under penalty of per�ury that 1 am exempt from the Contractors' State I.icense Law far the reason(s} indfcated belaw by
the checkmark{s construct, alter, fmprove, demolish, or repair any structure, prior to issuance, also requires the applicant for the permit
to �le a s(gned statement that he or shej I have piaced next to the applicable item(s) 5ection 7031.5 B�siness and ProfessEons Code: Any
city or county which requires a permft to ls Ilcensed pursuant to the provisions oi the Contractors' State License Law{Chapter
9(commencing with Section 7000� of Di�ision 3 of the Business and Prafessions Code] or ihat he or she is exempt and the basis for the
alleged exemptfon. Arsyviolation af Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than
five hundred dollars ($SOOj.j
I hareby affirm under penslty of perJury ONE of the foliowin$ daclaratMns (MIiST CHECK ONE OF THE FOLLOWI�fGj:
I, as owner of the property, or my employees wtth wages as their sale compensation, will c3o the work, and the structure is not
inteAded or offered for sale {Sec. 7044, Business and Professions Code: ihe Contractors' State License Law does not apply to an
owner of property who builds or impro�es the property, provided that the improvements are not intended or offered far sale. if,
however, the building or improvement ts sold wtthin one year of completion, the Owner-Builderwil! have the burden of prov�ng that
it was not built or improved for the purpose of safe.}
❑f, as owner of the property, am exclusfvely contracting with licensed contractors to canstruct the project (Sec. 7044, Business and
Professions Code: The Cantractor's License Law does not apply to an owner af property who builds or improves thereon, arsd who
contracts for such profects with a licensed contractor pursuant to the Contractors' State litense Law.}
❑ f am exempt from Licensure under the Contractors' State License Law for the follawing reason:
�_ , -�-� �;•� , „�. �
Date: � � � �` � PrEnt Name: �.�-.i �..��`.���_�i 1_I��..�� C�_ Signature: �„
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