09-0198 (RR)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: 0.9-0000:0=19;8:
Property Address: 49975 AVENIDA OBREGON
APN: 658-250-021- -
Application description: RE -ROOF
Property Zoning: LOW DENSITY RESIDENTIAL
Application valuation: 14850
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Owner:
SANTA ROSA COVE
P.O. BOX 12920
PALM DESERT, CA
(760)777-9225
HOA
92255
Contractor:
Applicant: Architect or Engineer: WESTERN PACIFIC ROOFING CORP
3462 LA CAMPANA WAY
PALM SPRINGS, CA 92262
C� (760)416-5877
Lic. No.: 235717
LICENSED CONTRACTOR'S DECLARATION -
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with
Section 70001 of Division 3 of the Business and Professionals Code, and my* License is in full force and effect.
License Class: BC39 _ LicenseNo- 235717 .
'e.O
OWNER -BUILDER DECLARATION
hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the
following reason (Sec. 7031 .5, Business and Professions. Cvde: Any city or county that requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to its 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 Contractor's_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 therefrom 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 1$500).:
(_ 1 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 thereon,
and who does the work himself or herself through his or her ownemploy`ees, 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 he or she did not build,or
improve for the purpose of sale.).
(_ 1 I, as owner oftheproperty, am exclusively contracting with licensed contractors to construct the project (Sec.
7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of
property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed
pursuant to the Contractors' State License Law.).
( 1 I am exempt under Sec. , B.&P.C. for this reason
Date:
Owner:
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the
work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name: _
Lender's Address:
LQPERMIT
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 3/03/09
riir� �`F LA f'a1917il7•n I
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations: '
_ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided
for 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. Myworkers' compensation
insurance carrier and policy number are:
Carrier CYPRESS INS Policy Number 33000053308081
_ 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 provisionsofSection
3700 of the Labor.Code, I shall forthwith'comply with those provisions.
Dat—re: T _7-/j/�FPPIi�'
&
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 I$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.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the
conditions and restrictions set forth on this application.
1 . Each person upon whose behalf this application is made, each person at whose request and for
whose benefit work is performed under or pursuant to any permit issued as a result of this application,
the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City
of La Quinta, its officers, agents and employees for any act or omission related to the work being
performed under or following issuance of this permit.
2. Any permit issued as a result of this application becomes nulland void if work is not commenced
within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject
permit to cancellation. '
I certify that I have read this application and state that the above information is correct. I agree to comply with all
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
of this county to enter upon the above-mentioned property for inspection purposes.
Date:, ' ISA'Signatur or Agent):
Application Number . . . . . 09-00000198
Permit . . . RE -ROOF
77
Additional desc .
Application Number . . . . . 09-00000198
Permit . . . RE -ROOF
Additional desc .
Permit Fee . . . . 30.00
Plan Check Fee
.00
Issue Date . . . .
Valuation . . .
. 0
Expiration Date . . 8/30/09
Qty Unit Charge Per
Extension
BASE FEE
30.00
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Special Notes and Comments
RE -ROOF INSTALLATION OF NEW TILE
UNDERLAYMENT INCLUDES 49-985,49-995
AVENIDA OBREGON 112007 CODES"
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Other Fees . . . . . . . BLDG STDS ADMIN (SB1473)
1.00
Fee summary Charged Paid
-------------------------------------
Credited
--------------------
Due
Permit Fee Total 30.00
.00 .00
30.00.
Plan Check Total .00
.00 .00
.00
Other Fee Total 1.00
.00 .00
1.00
Grand Total 31.00
.00 .00
31.00
LQPERMIT