HomeMy WebLinkAboutSPIN18-0005City of Palm Desert
Building Safety Department
PERMIT NUMBER:
ISSUED DATE:
and
73510 Fred Waring Drive
SPIN18-0005
2/15/2018 12:00:00 AM
Palm Desert, CA 92260
Appl. Date: 2/15/2018
Permit Type: SPECIAL INSPECTION
Permit
Subtype:
Job Valuation: $25,000.00
Appr. Date: 2J15/2018
Exp. Date: 8/14/2018
Project Address: 7 L
Project Description:
APN/Tract/Lot No:
Owner-,
Contractor:
Applicant:
655082002
JOHN W SIMONSEN
JOHN W SIMONSEN
TR 2521
73630 BROKEN ARROW TRL
73630 BROKEN ARROW TRL
14
PALM DESERT, CA 92260
PALM DESERT, CA 92260
Licensed Contractor Declaration
Fee_Summar�
I hereby affirm under pen 1y pf oejury that I am licensed under provisions of Chapter 9
ARCHIVE FEE-6.5X11 UP TO 11 X17 GL-1100000-3411600 $0.42
-
(commencing with Section 7000) of Division 3 of the Business and Professions Code,
and my license is In full force and effect.
GREEN BLDG FEE SB1473 GL-6100000-2281000 S4.00
Initial
MINIMUM INSPECTION FEE G L-1 100000-3221100 $159.00
PERM IT ISSUANCE FEE GL-1100000.3411400 $105.00
Owner -Builder Declaration
ElI
hereby affirm under penally of perjury that I am exempt from the Contractors' State
Total Fees Paid: $268.42
License Law for the reason(s) indicated belew by the Checkmark(s) f 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, after, 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 Bloom mencing with Section 7000) of Division 3 of the Business
and Professions Code) or that he or she is exempt and the basis for the al leged
print Name:
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).)
1, 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
SignatureofAppiicantorAgent:
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.)
Date:
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/Signature of property owner or agent
Workers' 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 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES,
I hereby affirm under the penalty of Deriury ONE of the following declarations:
-
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
Initial
3700 of the Labor Code, for the performance of the work for which this permit issued.
Policy No.
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:
Initial
Caroler & Policy Number
Expiration Date
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.
Initial
Date Applicant
-
(For Office Use Only)
JOB ID: 5P1/Y1 9 -' 0005
PLANS FILED:
Project Address: " �} uite #
Total Value of work: $ Note: Plan Review Fees maybe adjusted after Plan Review
Project Description (be specific): Tom,.! `ar V C' GCS Cl e / W ! 4 t ki e L4"7_
r' o a/ le- J.
k
E
Contractor Business Name
Property Owner Name
Address
Ad d ress I
3 O 0 /
city Zip
Ci Zip o
O�_fjcv
Phone
Phone -7 L/ O
Fax
Fax
E-mail
E-mail 5^
141 0 Y1 J'� tksPk�
Contractor License No.
❑Architect Name ❑Designer Name
Engineer Name
Address
Address
City Zip
city Zip
Phone
Phone
Fax
Fax
E-mail
E-mail
License No.
License No.
Applicant Name
1A)
Sign re
Date
� o
Contact Telephone Number
r-76'0) qa
E-Mail
PLEASE COMPLETE THE REVERSE SIDE
73-510 Fred Waring Drive, Palm Desert, CA 92260 • (760) 776-6420 • (760) 776-6392 fax • www.cityofpalmdesert.org
M