HomeMy WebLinkAboutELEC23-0024 DEC.pdfPALM DESERT PERMIT CENTER
73-510 Fred Waring Drive, Palm Desert, California
(760) 776-6435 gerrnitoentertyofpalmdasertarg
DECLARATION
90 (0
CONTRACTOR DECLARATION — CONTRACTOR LICif:
PERMIT 14: 5,1/6:' -1..)0ZA1
/ II 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 (ode, and my license is in 10 force and effect. ) agree to hove and maintran. a (7.11y. a Palm Desert
Business Ucense.
Worer"sCompensation Declaration: WARNING: FAILURE TO SECURE WORKERSCOIV1PENSATiOlsk COVERAGE IS UNLAWFUL AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (S1,00,000),, IN ADDITION
TO THE COST OF COMPENSATION DAMAGES AS PROVIDED FOR 1 N SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
1 hereby affirm under penalty of perjury ONE of the following declarations (MUST CHECK ONE OF THE FOLLOWING):
(.„) have and will maintain a certificate, of consent to self -insure for workers"' compensation, as provided for, by the Director Of
lindust rid) R elatiions as provided by Section 3700 of the Labor Code, for the performance iotlf the work 0r which this permit is issued,
II have and will maintain workers' compensation insurance, a5 required by Se,ction 3700 of the labor Code, for the performance of
Owe; Work for which this permit is issued. My workers' COmpens ration insurance carrier and poilicy nunther are,
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0, certify that in the performance of the work for which this permit IS iS:Sueci, I shall not employ any pe.rson in any manner 5,0 as to
become subject to the Workers" Compensat)on Laws of California,. and agree that if I should become siihject to ;Me wen kers'
coMpensation provisions of Sec tiO n 370,0 ol' the Labor Code, I shall forthwith comply with those provisions.
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OWNER BUILDER DECLARATION — PERMIT#:
II hereby affirm under penalty of perjury that I am exempt from the Contractors" .State License L,aw for the reasor6) indicated below by
t'he cheekmarkfis con.struct, a liter,: improve„ dernolish„ or repair any structure„ prior t 0 iSSi.Mnce,. arse, rtn the applicant for the permit
to file a signed Statement that. he ,or rifre) tl have placed next to the applicable item(s) Section 7031.5 Bi,.isiness and Professions Code: Any
city or county which requiires a permit to ts licensed pursuant to the provisions of the Contractors' State License !Lawfchapter
9(coramencing with Sect on 70001 of Division 3 of the Business and Professions Code) or that he ,or she js exempt and the basis for the
allieged exempdon. Anyviola don t)f, Section 7031.5 by arty ap p ficant for a permit subjects the applicant to a civil penalty of not more than
five hundred dollars (.5.5,00).)
I hereby affirm under penalty ef perjury ONE of the following de claTati an s (MUST CHECK ONE OF THE FOLLOWING);
c.-.) 1 as owner of the property, or my employees ithth wages as their sole compensation, willl 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 er )mproves 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 v 11 have the burden of proving that
it was not hudt or improved for the purpose of :sale.)
li, as owner ii3( the property, am excilustvely contracting with Incensed contractors to construct the project (Sec, 7044, BUSiness and
Profess)ons Code: The Contractor's License Law ,does not apply to an owner of property who builds or improves thereon, and who
contracts for 511C.11 oroj CCM With a iiicensed contractor p rso rIA to the Contractors' State License Law.)
am exempt from icensure under the Contractors' State License Law for the following Masori:
Date: Print Nartie,,
Signature.