09-0188 (RR)P.O. BOX 1504
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WORKER'S COMPENSATION DECLARATION
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA
92253
Application Number:0-9-=30
Property Address:4.9'976-AVENIDA
00001&8`3
OBREGON
APN:
658 -250 -020 -
Application description:
RE -ROOF
Property Zoning:
LOW DENSITY RESIDENTIAL
Application valuation:
15400
Tiht 4 4v Q"
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Applicant: Architect or Engineer:
Owner:
SANTA ROSA COVE HOA
P.O. BOX 12920.
LA QUINTA', CA 92253
(760)777-9225
Contractor:
WESTERN PACIFIC ROOFING
3462 LA CAMPANA WAY
PALM'SPRINGS, CA 92262.
(760)41675877
Lic. No.: 235717
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 3/02/09
D
110
PF MAR 0 r. :�I%j 11
j
TY OF LA QUINTA
FINAN!t::E L)EPT.
-
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LICENSED CONTRACTOR'S DECLARATION' -
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WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury. that I am licensed under -provisions of Chapter 9 (commencing with
I hereby 'affirm under penalty of perjury one of the following declarations:
Section 7000)'of Division 3 of the Business and Professionals Code, and my License is in full forcb�and effect. ., -
- I have and'will maintain a certificate of consent to self -insure for workers' compensation, as provided .
License Class: B C39 License No.: 235717
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is -
77
DateJ` 7 -�- Gontractoc:_ a
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
OWNER -,BUILDER DECLARATION -
I hereby affirm under penalty of perjury that I am exempt -from the Contractor's State License Law for the
insurance cairier'and policy number. are: '
Carrier CYPRESS INS Policy Number 330000533.08081
following reason'ISec. 7031 .5; Business and Professions'Code:'r Any city or county that requires a permit to
_ I certify that; in the performance of the work for which this permit is issued, I shall not employ any
construct, alter, improve, demolish; or repair any structure,,prio_'r fo its issuance, also requires the applicant for the
person in any manner so as to�become subject to the workers' compensation laws of California;
. permit to file asigned statement that he or she is licensed pursuant to the provisions,of the Contractor's State
and agree that, if I should become subject to the workers' compensation' provisions of Section
License Law (Chapter 9 (commencing with Section 7000) of.Division 3 of the Business and Professions Code) or
3700.of the Labor Code, l shall forthwith comply with those pro 'sions.
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 ($500).:
4
D,��ate:"�� c n :—/ � `
1 _ ) I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and
-App
the.structure is not intended or offered for sale (Sec. 7044, Business and Professioris'Code: The
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
Contractors' State License Law does not apply to an owner of property who builds or improves -thereon,
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE.HUNDRED THOUSAND
.and who does the work himself or herself through his or her own.employees,=provided that the
.DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
improvementsare not intended or offered for sale. If, however, the building or improvement is sold within
SECTION 3706 OF THE LABOR CODE, INTEREST, AND,ATTORNEY'S:FEES.
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 _ 1 I, as owner of the property, 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 _ 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.I.
Lender's Name:
Lender's Address:
LQPERMIT
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 null and 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 theabove-mentioned property for inspection purposes. yf
LQPERMIT
Application Number . . . . . 09-00000188
Permit . . . . . . RE -ROOF
Additional desc
Permit Fee 30.00
Plan Check Fee
.00
Issue Date . . . .
Valuation . . .
. 0
Expiration Date 8/29/09
Qty Unit Charge Per
Extension
BASE FEE
30.00
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Special Notes and Comments
RE- ROOF INSTALLATION OF NEW TILE
UNDERiAYMtNT. INCLUDES ADDRESSES -49-986,
49-996 AVENIDA OBREGON. 1-2007 CODES."
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Other Fees. . . . . . . . . . BLDG
STDS ADMIN (SB1473)'
1.00
Fee ' -summary. charged Paid
Credited
Due
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Permit* Fee Total 30.0.0
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.00 OD
30.00
Pl*An Check Total .00
.00 .00
..00
Other Fee Total 1.00.
.00 00:
1.00
Grand -Total 31.00
..00 .00•
.31.00