11-1052 (RR)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253.
Application Number: i,___11-00001052
Property Address:
5.4745_ RIVIERA
APN:
775-031-008- -
Application description:
RE -ROOF
Property Zoning:
LOW DENSITY RESIDENTIAL
Application valuation:
13000
Applicant: Architect or Engineer:
------------------
LICENSED CONTRACTOR'S DECLARATION
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414
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VOICE (760) 777-7012
FAX (760) 777-7011
BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING 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 Professionals Code, and my License is in full force and effect.
LicenseClass: C39 `7600
� tractore
p6:n
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, or repair any structure, prior to its issuance, also requires the applicant for the
permit t0 file a signed Statement that he of She.is IieenSed pursuant to the prdvision5 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 ($500).:
(_) 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 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, 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 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 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
Owner:
PGA HOA
54320 SOUTHERN HILLS
LA QUINTA, CA 92253
Contractor:
BRS ROOFING INC
465 S. LUGO
SAN BERNARDINO, CA 92408
(909)496-3113
Lic. No.: 907600
Date: 9/29/11
Oe
CCT 0 , 2011
CITY OF LA QUINTA
FWA CE RFPT.
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.
VC -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:
Carrier STATE FUND Policy Number 238403010
_ 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 C de, I shall forthwith cUIIrphMMµ se provisions.
te: !� —!A cant: �TT
000
WARNING:. FAIL RE 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.
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 construc'on, and hereby authorize representatives
of this county to enter upon the above-mentioned property for inspectio es.
6ate:, ature (Applicant or Agentl:
Application Number •11-00001052
Permit . . . RE -ROOF
Additional desc .
Permit Fee . . . . 30.00
Plan Check Fee
.00
Issue Date
Valuation.
0
Expiration. Date 3/27/12
Qty Unit Charge Per
Extension
BASE
FEE
30.00
Special Notes and Comments
SWEEP GRAVEL THEN APPLY COOL.ROOF RATED
POLYURETHANE FOAM ROOF SYSTEM.
2010 .
CODES. INCLUDES ADDRESS 54-721.
---------------------- -----------------------------------------------------
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