07-2324 (RR)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: 07_0°00023,2
Property Address: 52228 AVEN�IID OBREGON
APN: 773-215-010-11 -000000-.
Application description: RE -ROOF
Property Zoning: COVE RESIDENTIAL
Application valuation: 500
Applicant: Architect or Engineer:
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LICENSED CONTRACTOR'S DECLARATION
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
I hereby affirm under penalty of perjury that.) -am licensed under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professionals Code, and my'License is in full force and effect.
License Class: .License No.:•
Date: Contractor:
OWNER -BUILDER DECLARATION'
I 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 Code: Any. city or county that requires a permit to
construct;'alter, improve, demolish;'ornrepair 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,theZontractor's State
License Law (Chapter9 (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 7.031.5 by ;
a.rWapplicant for a. permit subjects the applicant to a civil penalty of, not more.than five hundred dollars ($500).:
1 1 .l, as owner of the property, or my employees with wages as their sole compensation, will do the work, and
the structure isnot intended'or offered for sale (Sec. 7044, Business and Professions Coder 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 own employees, provided that the
improvements are not intended or offered for sale. If, however, the building or improvement is sold within
one .year of completion, theowner-builder will have the burden of proving that he or she did not build or
improve for the purpose of sale.).
( I 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 a contractor(s) licensed
pursuant to the Contractors' State License Law.).
(_) Lam exempt Vder Sec. - , B.&P.C. for this reason 7/
ate: caner.
7/vaffi/under
CONSTRUCTION LENDING AGENCY
I here 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: ,l
Lender's Address:
LQPERMIT
Owner:
KAHN MIRIAM
P —"BOX 936
L_4,r o INTA, CA 92253
Al IG 15 2007
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 8/16/07
WORKER'S COMPENSATION'DECLARATION
I hereby affirm under penalty, of perjury ane 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 irisurance,.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:
Carrier Policy Number, '
1 certify that, in the performance of the work for which this permit is issued, 1 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-woikers' compensation provisions of Section
3700 of the Labor Code, I shall forthwith comply with those' provisions.
/�plic/ant:
C WARNING: FAIL RE TO WORKERS' COMPENSATION COV RAGE 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.
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 d swill subject
permit to cancellation.
I certify that I have read this application and state that the above information is correct. I agree c6' ly with all
city and count ordinances and state laws relating to building construction, and hereby autho ' e r sentatives
of this c t toe er upon the above-mentioned property for inspection purposes.
Da dr nature (Applicant or Agent):
I
LQPERMIT
Application Number . . . . 07-00002324
Permit . . . . .
. RE -ROOF
Additional desc .
.
Permit Fee . .
30.00
Plan Check
Fee
.00
Issue Date . . .
.
Valuation
. . .
. 0
Expiration Date
2/12/08
Qty Unit Charge Per
Extension
BASE FEE
30.00
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Special Notes and
Comments
REPAIR AND REPLACE
ROOF WITH CLASS "A"
MATERIALS
Fee summary
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Charged Paid
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Credited
----------
----------
Due
Permit Fee Total
30.00
.00
.00
30.00
Plan Check Total
.00
.00
.00
.00
Grand Total
30.00
.00
.00
30.00