04-3636 (RR)BUILDING &. SAFETY -DEPARTMENT
P.O..Box 1504 (7.60) 777=7012
78-495 CALLS -TAMP1Co FAX (760) 777-7011
LA .Q.'UINTA, CALifORN.IA 92253 INSPECTION REQUESTS (760).777'-7153
BUILDING PERMIT
App-lication.Number
C04-00003636 Date 4/21/04
Property Address
5-5-92-0—RIVIERA----
API:
775-2417044'-
-Application description
RE -ROOF
Property Zoning
:.LOW DENSITY RESIDENT3AL
ApPli.cation. valuation
3500
Owner
Contractor
CHAMBERLAIN JOHN/LISELOTT
EMERALD ROOFING INC
559.20 RIVIERA.
P.O. BOX 1.963
.ISA `QiTINTA: .
PALM -DESERT , .
CA '9.2:2.61'
WCC: STOVE INS
91C%804 :
W ...:
;C 63 .
:
Ol/Ol/OS
-
C S:LB: 7709�Q:
0
:.11/30/ 5
CC.0 : C3 9
Permit . . . RE -ROOF
-Additional :desc
Permit Fee . . . 30.00 Plan Check Fee.
.00
I.ssue- Date
..Valuation
0
Qty. Unit Charge.' P.er
Extension
BASE.FEE
30 0.0
Special Notes and Comments'
- ...
RE = ROOF . WI TH POLYF'OAM
Fee summary Charged
Paid Credited
Due
Permit Fee..Tot.al 30.: 00
0:0 : 00: ,
.30..00.
'..Plan..Check Total : ' 00
:'..00 00, :.:`
Go*..
Grand Total ::3;0....0:0'.-;::',:
00 ..00:
3000'
_ 2
3
�
4�
P.O. BOX 1504 a vv
78-495 CALLE TAM►ICO _
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
Application Number.
Applicant:
MApplicant's Mailing Address:
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date:
Architect or Engineer.
.Architect or Engineer's Address:
Lic. No..
JIB
BUILDING PERMIT DECLARATIONS .
hereby affirm under LICENSED CONTRACTOR'S DECLARATION
1
pWWKY d Perjmxy #W 1 am licensed under provisions of Chapter 9 (commencing with section 7000) of Division 3 of be Business ane Prolessionak
pass License S force and eBect License NoD O
Date •`i -.Z � � o .
OWNER$ULDER DECLARATION
I hereby affirm 4nder peter of pwjwr that I Wn exempt from the COntraclore State License Law for the bMowirp mason (Sec 70:11 6. Bushiness and Professions Code: Any
citY or oomxriy that L permit b oornstruct, albr. irtpr ove. demnoist or repair any structure. prior b is issuance, also requires the appicmnt for the permit b file s signed
ctalemernt
that he or she k licensed pursuant b tie provislonc Of be Contracbm State License Law (fifer 9 (cannoning with Section 7000) of Division 3 a the Business
and Professions Code) or that he orshe is exempt beiefiom and the basis for the alleged exertpGan. Any violation of Section 7031.5 by any applicant for a pmmil subjects
Me applicant to a cion penalty of not more than 6m hundred dollars (5500).)
U I. as 0wner.Of the proP011ri or my employees with wages as their $016 oomPwml ion..will do be work and be structure is not intended or often;0 for sale (Sec. 7044,
Business and Professions Code: The Cgetracbrs' State license Law does not appy b an Owner of property who builds or improves thereon; and who does the wok
him sa or hmmxt or through his or her own employees, provided that be improvements aro not intended or offered for sale K however, the buidag a improvement is
add within ane year Of completion; the owher-builder will have be burden of pmvkV that he or she did not build or improve for the purpose of sale.}
U Las owner of.lhe property. am exclusively contracting with licensed contracbns b construct the project (Sec. 7044. Business and Professions Code: The Contractors•
Stab License Law does not apply ban ow nen at property who builds or improves theme n, and who contracts for the Projects with a contractor(s) icensed pursuant to
the Contractors' Stalie License Law.).
U 1 aim exempt under Sec. a.3 P -C. for this reason
Gate . Owner .
1 affirm under WORKERS' COMPENSATION DECLARATION
hereby a
penalty d perjury ane of be following declarations:
_ 1 have and will maintain a certificate of consent to sel-Insure for workers' caepensa6m 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 compensation hnsuranoe, as required by Section 3700 d the Labor Code. for the performance of the wok for which this pernW is
issued. waken' co enratron—o:anler and policy nunbet are:
ber
_ I omtify IhK in he Po romance of the work for which this pennit is issued. l ahai not
compensation laws of California. andploy air Person in any manner 3700 to bsubject b the workers'
agree VOLtmaL i< 1 starAd become subject b the wodcerc' compensation provisions off Section 3700 d the lobo Code. l:tial
forthwithcomply mmmiti loose provisions. .
^0�-
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL Si OBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE lfl MED TFIOUSANO DOLLARS ($100.000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, WEREST, AND ATTORNEY'S FEES. .
CONSTRUCTION LENDING AGENCY
affirm hereby aunder penalty d perjury that there is a construction lending agency for the penfamnance of the work for which this permit is issued (Sec. 3097. Civ. C.).
'Lenders Name
Lenders Address
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Appicaf or► is hereby made to ba Oimcbr of Bu60ing and Safety for a.Pemnit subject to the conditions and restrictions set forth on this application.
I- Each person upon whose behalf this appicatim Is made. each person at whose request and for whose benefit work Is performed hinder or pursuant b any permit
issued as a agentsuft of this appica6on, the runner, and the iPpficant, each agrees b. and $hhad, defend. hndemrWy and hold harmless the City of La Ouinta. its
2 Armr Pim slssuod as�yees any
e act «O�sion related to the work being performed under or folleowing issuance d this permit.
ppica6m becomes null and void if work is not commenced within 160 darys from date of Issuance of such pemnit, or
cessation of work for 160 days will subject permit b canoedation.
I certify that •I have read this application and state that the above hiformation is cored. I agree to comply with a6 city and county ordinances and state laws relating b budding
tmemby authorize representatives of this county to ewer upon the above-mentioned property for inspection purposes.
.Date':L `—o Signature (Applicant or etrt