06-2046 (RR)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA; CALIFORNIA 92253
Application Number:06-00002046
- WORKER'S COMPENSATION DECLARATION
Property Address:
53080 AVENIDA OBREGON
APN:
7747045 -005 -5 -000000 -
Application description:
RE -ROOF
Property Zoning:
COVE RESIDENTIAL
;•t Application valuation:
1200
Applicant:
Architect or Engineer:
• Qw*e6j
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Owner:
TAMBLE M/M MICHAEL R
53080 AVENIDA OBREGON
(1 LA QUINTA, CA 92253
--------------
=----------------
--
MAY 1 7 2006 Contractor:
Owner
CITY OF lA QUINTA
FINANCE DEPT
----------------------------------
Date: 5/16/06
- LICENSED CONTRACTOR'S DECLARATION
- WORKER'S COMPENSATION DECLARATION
I hereby. Aiim under penalty of perjury that I.am licensed under provisions of.Chapter 9 (commencing with
I hereby affirm under penaltyYof.perjury one of the following declarations:.' .
- Section'70001-of Division�3 of the Business and Professionals Cotle, and, myLicense is iri full force and effect.
- . I have and will maintain a certificate of:consent toseli-insure far workers' compensation; as provided
-License Class: License No.:
...
for tiy. Section 3700 of the Labor Code, for the performance of the workforwhich this permit is
-
..
Date: !! �. Contractor:
. 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 _
insurance carrier and policy number are:
hereby affirm under penalty of;perjury�that I am exempt from the Contr`actor's State License Law for the
Carrier' - Policy Number '
following reason (Sec. 7031.5, Business and Professions Code: Any city_ornounty.that requires a. permit to
I certify that, intheperformance of the work for which this permit is issued, I shall not employ any
construct, alter, improve,. demolish; or repair any structure, prior to its: issuance, alsorequires the applicant for the
person in any manner so'asto become subject to the workers' compensation laws of California,
' 1"A .permit to file a signed 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 Section7000)ofDivision 3 of the Business and Professions Code) or
3700 of the labor Code, I all forthwith comply with. oseprovisions.
that-heo`she is exempt therefrom and the basis for the alleged exemption.. Any violation of Section 7031.5 by
�."
pplicant fora permit subjects the applicant to.a civil penalty of not more than five hundred dollars (
Date: Applica� nt: � lc/1yt
work,.:
` I, as'owner of the�pioperty; or my.employees with wages as their sole comperisation, will do•the'work, and
—
the structure'isnot intended or offeretl for saleISec. 7044,.Business and Professions 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 workhimself or heiself.through his or her own employees„provided that.the -
DOLLARS (S10O;000). IN ADDITION TO THE COST'OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
.. iritprovements.are not intended or offered focsale. If; however, the building or 'improvement is sold.within
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS 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.)
APPLICANT ACKNOWLEDGEMENT _
' 1 _ 1 I, as owner of the property, am exclusively contracting with licensed contractors to construct theproject(Sec.
�1.
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the
7044, Business and Professions Code: The Corttractors' State License Law does not apply to an owner of
conditions and restrictions set forth on this application. '
property who builds or -improves thereon, and whocontracts for the projects with a contractor(s) licensed
1 .' Each person upon whose behalf this. application is made, each person at whose request and for
pursuant to the Contractors'. State License Law.). '
whose benefit work is performed underor pursuant to any permit issued as a result of this application,
1 1 I am exempt. under Sec. , B.&P.C. for this reason
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.'
Date:` ((,- 6(47 Owner:
2. Any permit issued as a result;of this application becomes null and -void if work is not commenced
within 180 days 4rom date of issuance of such permit, or cessation of work for 180 days will subject
-
CONSTRUCTION LENDING AGENCY
permit to cancellation.
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the
Icertify that I have read this application and state that the above information is correct. I agree to comply with all
work for which this permit is issued (Sec. -3097, Civ. C.).
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
Lender's Name:
of this county to•enter upon.the above-mentioned prope r inspection purpose
-
""ace: �� Signature (Applicant or Agentl:��.�--,—+
Lender's Address:
c
LQPERMIT
Application Number . . . . . 06-00002046
Permit . .
. RE -ROOF
Additional desc .
Permit Fee . . .
. 30.00
Plan Check
Fee
.00
Issue Date . . .
.
Valuation
. . .
. 0
Expiration Date
11/12/06
` Qty Unit Charge
Per
Extension
BASE FEE
30.00
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Special Notes and
Comments
REROOF COMPOSITION
SHINGLES. CLASS"A"
MATERIALS ONLY.
Fee summary
Charged Paid
Credited
Due'
Permit'Fee Total
30.00
.00
.00
30.00
Plan Check Total
.0.0
.00
.00
.00
Grand Total
30.00
.00
.00
30.00
LQPERMIT
Bin #
City :of La .Quints:
Building 8I Safety Division
P:0. Box 1-504,': 78-49.5 Calle Tampico
La Quinta, CA 92253 - (760)-777-7012
Building-pet-mit Appl cat'o and Tracking Sheet
Permit #
Project Address: 1 1vQ Q
Owner's Nam : �' • Qe
A. P. Number:
Address;. O N Lo I d a b to Ce2 O
Legal Description:
City, ST, Zip: cc .Aa5
Contractor: QZZ
.
Telephone. CO . — 3' •
Address:
Project Description:
City, ST, Zip:
O. S
:Telephone:
State Lic. # :
City Lic. #:
Arch.; Engr., Designer:
Address:
City, ST, Zip:
Telephone:
State Lic. #:
Name of Contact Person: NI 1 �� Q m�,
,Construction Type: Occupancy:
Project type (circle one): New Add'n Alter 6ep r Demo
'Sq. Ft.: I oo
#Stories:
# Units:
Telephone # of Contact Person: �31q
Estimated Value of Project: lZ 0:;,
APPLICANT: DO NOT WRITE BELOW THIS LINE
N
Submittal
Req'd
Recd
TRACING -
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Cates.
Called Contact Person
Plan Check Balance
Energy Calcs.
Plans picked up
Construction,
Flood plain plan.
Plans resubmitted
Mechanical
Grading, plan"
2"d Review, ready for corrections/issueElectrical
Subcontactor. List
Called Contact Person
Plumbing
Grant Deed
Plans.picked up
S:M.I.
H.O.A. Approval '
Plans resubmitted
Grading
IN HOUSE:-
''" Review, ready for corrections/issue
Developer 'Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
OWNER/BUILDER INFORMATION
Dear Property Owner:
An application for a building permit has. been submitted in .your name listing:yourself as the builder of the property
improvements specified.
For your protection you should,be aware that as "Owrier/Builder" you are the. responsible.party,of record on such, a
permit..Buddingpermits are not required to, be-signed.by.prope ty owners unless they are personally performing -their
own work. If your work ig. being performed by someone otlier4hari yourself, you'may.protect yourself from possible
liability if that person applies for the -proper permit in his or her name.
Contractors are required bylaw to be licensed and, bonded by the State. of ,California and- to have a business license
from the City or County. 'They are also required bylaw to. put their license number on'all permits for which they
apply.
If you plan to do your.own work, with the exception of various' trades that, you plan to subcontract, you should be
aware of the: following information for your benefit and protection:
If you employ orotherwise engage any persons other your immediate=family,.and the -work (including materials
and other costs) is $200.00 or more for', the entire prbject,. and such persons,;are •not -.licensed as contractors or
subcontractors, then you may be. an employer.
If you are an employer, you must register with the State and Federal Government as an employer and you are subject
to several obligations include State, and Federal income. tax withholding federal social security taxes, worker's
compensation insurance, disability insurance costs and-;unemploymentcompensation, contributions.
There may be financial risks for you if;you do not carry out -these obligations, and•thesexisksiare especially serious with
respect to worker's compensation insurance.
For more specific information about your., obligations under Federal Law, contact%the Internal Revenue Service (and, if
you wish, the 'U.S: Small Business`'Administration). For�more �specific'information.about your obligations under State
Law, contact the Department of Benefit Payments and the,'Division.of,Industrial Accidents.
If the structure is intended for sale; property. owners who are 'not, licensed contracts are #allowed to perform their
work personally or through their own employees, without -'a- -'a licensed contractor:or.subcontiactor, only under limited
conditions. - r
A frequent practice of unlicensed. persons, professing to be contractors is to.secure an `.0wtier/Builder" building
permit, erroneously implying- that- the property owner is providing his: or her own labor, and material personally.
Building permits are not- required to be signed -by property. owners "unless they are performing their own work
personally.
Information about licensed contractors may be obtained by, - contacting the Contractors' State License Board in your
community or at 1020 N. Street, Sacramento, California 95814.'
Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of
these matters: The building permit'will not be issued 'until the verification".is returned.
Very truly yours,
CITY OF I.A. QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
La Quinta, CA 92253
(760) 777-7012
FAX: (760) 777-7011
OWNER'S SIGNA/T�URE/DATE
PROPERTY ADDRESS
PERMIT NUMBER(S)