10-0967 (RR)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: '10-00000967
Property Address: 55090 RIVIERA
APN: 775-153-069-
Application- description:
75-153-069-Applicatiorndescription: RE -ROOF
Property Zoning:1 LOW DENSITY RESIDENTIAL
Application valuation: 23788
Applicant:
Architect/' `✓or Engineer:
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter T(commencing with
Section 7000) of Division 3 of the Business and Professionals ode, and my License is in full force and effect.
License Cit 39-B cIt o.: 885157
Date: qlovContractor7that
IF -
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of pexempt from the Contractor's State License Law for the
following reason (Sec. 7031.5, Bofessions Code: Any city or county that requires a permit to
construct, alter, improve, demolisy 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'($ 500).:
1 _ 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 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, 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
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760).777-7153
Owner:
PGA WEST RESIDENTIAL ASSOC.
54500 WEST RESIDENTIAL CLUB DR
LA QUINTA, CA 92253
Contractor:
BIENEK ROOFING CONSTRUCTON
9707 PINEWOOD AVENUE
TAJUNGA, CA 91042
(760)625-7796
Lic. No.: 885157
Date: 9/20/10
AL
21
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C� t Y F� R ,1 Qt,1i•'4 7M
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1 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. My workers' compensation
insurance carrier and policy number are:
Carrier STATE FUND Policy Number 1889944
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
� of the Labor Code, I s I for w' comply with those provisions.
Date: Applicant:
WARNING: FAILURE TO SECURE W KERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRI AL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($100,000). IN ADDIT 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 construction, 2A hereby authorize representatives
of this cou4toer upon the above-mentioned prope y for inspec 'on r ses.
Date:Signature (Applicant or n0.
Application Number. . . . . . 10-00000967
Permit . . . RE -ROOF
Additional desc .
Permit Fee . . . . 30.00
Plan Check Fee
.00
Issue Date . . . .
Valuation . . .
. 0
Expiration Date 3/19/11
Qty Unit Charge_ Per
Extension
BASE
FEE
30.00
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Special Notes and Comments
RE -ROOF VACUUM ROCK- APPLY SPRAY
FOAM
ROOFING SYSTEM WITH TITLE 24 REFLECTIVE
TOPCOAT.2007 CODES. 55090, 55100,
55110,
55120 RIVIERA.
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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