HomeMy WebLinkAboutCity of Palm Desert Declaration updated 91421PALM DESERT PERMIT CENTER
73-510 Fred Waring Drive, Palm Desert, California
(760) 776-6435 permitcenter@cityofpalmdesert.org
DECLARATION
CONTRACTOR DECLARATION – CONTRACTOR LIC#: PERMIT#:
I 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 Code, and my license is in full force and effect. I agree to have and maintain a City of Palm Desert
Business License. You can apply for a business license at www.https://palmdesert.hdlgov.com
Worker’s 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 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
I hereby affirm under penalty of perjury ONE of the following declarations (MUST CHECK ONE OF THE FOLLOWING):
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 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.
Date: Print Name: Signature:
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 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) 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 is licensed pursuant 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 subjects the applicant to a civil penalty of not more than
five hundred dollars ($500).)
I hereby affirm under penalty of perjury ONE of the following declarations (MUST CHECK ONE OF THE FOLLOWING):
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: 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: Print Name: Signature: