RR (11-0594)76973 Calle Mazatlan
11-0594
P.O.. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 6/06/11
Application Number: jr?;-o-0 000 5 94Owner: Irl
Property Address: 76973^CALLE MAZATLAN SANTA ROSA COVE HOA" ,t.'("` -
APN: 658-230-021- - - PO BOX 12920
Application description: RE -ROOF -PALM DESERT, CA 92255 j J )I IA Ir) ,J
y :t
Property Zoning: LOW DENSITY RESIDENTIAL , ;. L ! 206 I
Application valuation: 17600
Contractor:
Applicant: Architect or Engineer: WESTERN PACIFIC ROOFING CORP
3462 LA CAMPANA WAY
PALM SPRINGS, CA 92262.
(760)416-5877
LiC. No 235717
LICENSED CONTRACTOR'S DECLARATION WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with 1 hereby affirm under penalty of perjury one of the following declarations: -
Section 7000) of Division 3 of the Business and Professionals Code, and my License is -in full force and effect. _ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided
Lice e C s: B C39 License N 35717 for by Section 3700 of the,Labor Code, for the -performance of the work for which this permit is
f✓or issued.
Date: d_,' X.ontr.ctor: / i. 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 workerscompensation.
OWNER -BUILDER DECLARATION insurance carrier and policy number are: .
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the Carrier ZURICH AMERICAN Policy Number WC672422800
following reason (Sec. 7031.5, Business and Professions Code: Any city or county that requires a permit to _ I.certify that, in the performance 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, also requires the applicant for the person in any manner sous to become subject to the workers' compensation laws of California, "
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 su
bject to the workers' compensation provisions of Section
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 3700 of the Labor Code, I shatIply with th a rovisions.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).: te: it Ap ant: -
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 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 woik himself or herself through hisor her own employees, provided that the - DOLLARS ($100;000)• IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
improvements are not intended or offered for sale. lf, however, the building or improvement is sold within SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S 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 I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. IMPORTANT Application is hereby made to the Director of Building. and Safety for a permit subject to the
7044, Business and Professions Code: The Contractors' 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 who contracts 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 under or pursuant to any permit issued as a result of this application,
(_ 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: Owner: 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
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 I certify 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 .
oth's cou y enter upon a above-mentioned property for i cti ur s,
ose
Lender's Name: /l/® _
fale
G Si ature (Applicant or Agent):
Lender's Address: f
LQPERMIT .
LQPERMIT - -
" Application Number 11-00000594
Permit . . . RE -ROOF
Additional desc ".
Permit Fee . . 30.00 Plan Check
Fee
.00
Issue Date . . . Valuation
0
Expiration Date 12/03"/11
Qty Unit Charge Per
Extension
BASE FEE ":
30.00
----------------------------------------------------------------------------
Special Notes and Comments.
TAKE OFF EXISTING TILE, INSTALL NEW
UNDERLAYMENT & REPLACE ORIGINAL TILE.
INCLUDED UNITS AT 76-983, 76-993 &
77-003. 2010 CODES.
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 - -