04-3626 (RR)
79713 Arnold Palmer
IIIIIII VIII III VIII IIII 44
1E
c'3 S
BUILDING &.SAFETY DEPARTMENT
•c ¢ P.O..BOX 1504 (7.60) 777=7012
OFTt '9 78-495 CALLS TAMPICO FAX (760) 777-7011
LA .Q.UINTA, CALIFORNIA 92253 -INSPECTION REQUESTS (760).777-7-153-
BUILDING PERMIT
Application .Number 04-00003626 Date 4/21/04
Property Address . . <7-97-13 ARNOLD PALMER
APN: 775-241-039- - -
- A.ppplication description RE-ROOF
Property Zoning .. :.LOW DENSITY RESIDENTIAL
Application valuation 7500
Owner Contractor
------------------------ -------=----------- ----
PETERSON JOHN R/JACQUELINE-M - EMERALD ROOFING INC
128 W. .-SUMNER .AVE P.O. BOX .1963
.SPOKANE' .WA PALM -DESERT . :` CA 9.2.261
SEBRING FL. 99204: .
WCC' STOVE INS.:
6391.0..8.04. 01/01/05
C
.. : . ...., -.. SLB: :.. :.: :..77094.4 .1.1/30/05
CCC: C3`9 '
Permit RE-ROOF
Additional desc
Permit Fee . 30 .::00 .. Plan Check Fee . 00
Issue Date Valuation 0
`Qty Unit Charge Per -Extension
BASE FEE . 30 . 00
Special . Notes and 'Comment`s
RE-ROOF- .WITH POLYFOAM
Fee summary Charged . Paid' Credited Due
`. Permi.t .Fee Total :-. ..:. .30.. 0o . .30- 00 -
- .. 00 : : 0Q: 30- 00 -
Plan Check Total 00: ..00 ..00 . 00
Grand Total. 30'. 00. 00 . . 00 30 . 00
P.O. BOX 1504
VOICE (760)777-7012
78-495 CALLE TAMPICO cu FAX.(760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number: 3(0a160 Date:
Applicant: Architect or Engineer.
Applicant's Mailing Address, Architect or Engineer's Address:
N f•�
Uc.No.
BUILDING PERMIT DECLARATIONS .
LICENSED CONTRACTOR'S DECLARATION
I hereby affinn under penally of perjury thou 1 am licensed under provisions of Chapler 9(cor mencinp wth Section 700.0)of Division 3 of to Business and Professionals
Coda.and myL bolas it foroe and effect
class -- rb�+,�e—No. ��c d
OWNW-BUILDER DE
I hereby Mmh tinder penalty of porFuy tat I am oxen"from le Contractors•Stale License Law for the following reason(Sec.703.1.5.Business and Professions Code: Any
city or county that MOM s permit b construct,alter.improve.demofisl►.or repair any Wuctum prior b its issuance.also requires the applicant for the permit to fie a signed
stalenwt that he or she Is licensed pursuant in the provisions of aro ConVadors•State license Law(Chapter 9(Comsrencing with Section 7000)of Division 3 of the Business
and Professions Code)or that he orshe is exempt lerefmom and the basis for ora aieged exempdort. Any violaioo uK Section 7031.5 by any applicant for a permit subjects
the applicant b a riot penally of not mare than five hundred dollars(5500).r
U 1,as ownet.of"property,or my employees with wages as their sole compensation.-will do lie work rind the structure Is not intended or dlered for sale(Sec.7044,
Business and Professions Code: The Contractors'Stab Lkoense Law does not appy to an owner of property who builds or improves thereon.and who does are wok
tinsel or herself or through his or her own employees,provided that ft improvements aro not Intended or offered for sale. If,however.the buriofshp or improvement is
sold within one year of completion.the owner-biiider:vA have the burden of prowV that hear she did not build or Improve.for aro purpose of sale.].
U L as owner of the properly.am exclusively Contracting with licensed contractors b construct the project(Sec.7044.Business and Protesstohs Code: The Carwactore
Site License law does not apply b an owner of property who builds or improves lhoieon,and who contracts for the projects with a contractor(s)licensed pursuant to
the Contractors'State License Law.).
U I air exempt under sec. S.3 P.C.for this reason
Date 1Jmvaer
1 hereby affirm under Wim'COMPENSATION DECLARATION
Penalty of penny one of the following declarations:
—I have and willmaintain a certificate of consent b self-irsue for workers'compensation.as provided for by Section 3700 of the Labor Code,forthe performance
of the work for which this permit Is issued.
I have and maintain workers'compemsa6om insurance.as required by Section 3700 of the Labor Code.for the performance of the work for which on permit is
, workers'cOnVe satian_k carrier and policy number are:
cy Number
—1 Certify that,In the perlon nmmce of the work for which ars
Compensation laws of California.and permit is issued.I shah not employ any Denson In any roamer so as.to become subject b the workers'
agree that•if I should become subject b the workers'compensation provisions of Section 3700 of the Labor Code.I shat
forhvtth.Compty with lase provisions.
eol
WARNING: FAILURE 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,*nFREST,AND ATTORNEYS FEES. .
CONSTRUCTION LENDING AGENCY
1 hereby affirm under penalty of perjury that two is a Construction lending agency for the performance of the work for which this permit is issued(Sec.3097.Civ.C.).
Lender's Name
Lenders Address
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 appicaiorL
1. Each Person upon whose behalf ars application is made,each person at.whose mutest and for whose benefit work is performed under or pursuant to any permit
issued as a result of ars application,the owner,and the appficaM,each agrees b,and shat.defend.indemnify and hold harmless the City of La Ouinta,itsofficers,agents and employees for any ad 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 beoomes null and void K work is not comrnenced within 160 days from date of issuance of such pemrl or
cessation of work for 180 days will subject permit b cancellation.
I certify that I have read tis application and state that the above information is correct. I agree to comply with at city and county on inanc6s.and state laws relating to building
construction,and hereby autwrze�representatives of this county b enter upon the above4nenfioned property for Inspection Purposes.
Date –0'�'9rrakure(Applicant or Agent):