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11-1062 (RR)P:O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 $0-72/ $-d-7 3.3 4GuVOICE (760) 777-7012 FAX• (760) 777-701:1 BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153 BUILDING PERMIT Date: 9/U/11 Application Number: 11-00001062 Owner: Property Address: 80119 CHERRY HILLS PGA HOA D D APN: 775-132-013- - - 54320 SOUTHERN HILLS Application description: RE -ROOF LA QUINTA, CA 92253 nn Property Zoning: LOW DENSITY RESIDENTIAL Application valuation: 13000 C11Y Of !.A pUINiA Contractor: FIHa�rEIDS C Applicant: Architect or Engineer: BRS ROOFING INC 465 S. LUGO SAN BERNARDINO, CA 92408 (909)496-3113 �J a LiC. No.: 907600 - ---------------------------•----------------------- 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 Professi 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 License Class: C35 U , r�907600 foabySection 3.700 of the1abor Code, for the performance of the,work for which this permit is issued. or: - ��� 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 &issbed. My workers' compensation 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 STATE FUND Policy Number 238403010 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 thispermit is Issued, I shall not employ any construct; alter, improve, demolish, or. repair any structure, prior to its issuance, also requires thedapplicant-for the person in any manner so as to become subject to the workers' compensation laws'of California, permit to,file a signed statement that he, or she. is liCensed,pursuamto the provisions of the Contractor's•Stete, and agree that, df I should become:sPikkez to'the workers' compensation provisions of Section License Lew (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions , I sh Code) or 3700 of the Labor eall forthwith cothose provisions. that he or she Is exempt therefrom and the basis for the alleged exemption Any violation of Section 7031.5 bye? 1 / any applicant for permit subjects the applicant to a civil penalty of not more.than five hundred dollars ($500).: stein -3 ^ A nti 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 sate (Sec. 7044, Business and ProfessionsCode: The WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE.IS UNLAWFUL, AND SHALL Contractors' State License Law does not apply to an owner(of property whobuilds or Improves thereon, SUBJECT AN EMPLOYER T.0 CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND and who does the work himself or herself through his or her own employees, provided that the, DOLLARS (5100,000)„ IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS'PROVIDED FORIN improvements are not: intended or offered for sale. If, however, the building or improvement Is sold'within SECTION 3708 OF THE LABOR CODE, INTEREST, rAND 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.). 1 _ 1 I, as owner of the property, am exclusively contracting with licensed contractorsto construct•the project (Sec. 7044, Business and Professions Code: The Contractors' State License Law does hot 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 _ 1 I am exempt under.See. 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, Clv..CJ. Lender's Name: Lender's Address: LQPERMIT APPLICANT ACKNOWLEDGEMENT IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject_ to the conditions andrestrictions 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 aresult .of this'application, the owner, and the.applicant, each agrees,to; and shall defend, indemnify and hold harmless the City of ka.Quinta, its;officers, agents -and employees for any act or omission related to thezwork 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, orcessation of work for 180 days will subject permit to cancellation. I certify that) 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 d_ hereby authorize representatives of this county to enter upon the above-mentioned - 'perty fw inspection pCo urp ture (Applicant or Agent): -,! Application Number '. . . 11-00001062 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 ADDRESSES 80-7.21 & 80-733. ----------------------- ------------------------------------------ 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 .3.1.00 LQPBRMIT