07-2618 (RR)P.O. BOX 1504
78-495 CALLE TAMPICO
LAQUINTA, CALIFORNIA 92253
jL
Application Number: 07-00002618
Property Address: 55568 PINEHURST
APN: 77S-241-005- -
Application description: RE -ROOF
Property Zoning: LOW DENSITY RESIDENTIAL
Application valuation: 7450
` Applicant:
Architect or Engineer:
LICENSED CONTRACTOR'S DECLARATION
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
1 hereby affirm under penalty of perjury that I am licensed.under provisions of Chapter 9 (commencing'with
Sectiow7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect.
License.Class: C39. .License No.: 770.940 '
Date: " 6 '"{ 0 'Contractor: T2=t
.OWNER =BUILDER DECLARATION
I. hereby affirm under penalty, ofperjury that I am exempt from the Contractor's State License Law for the
following reason (Sec..7031.5; Business and Professions Code: Any city or county,that requires a permit to
construct,' alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the
per 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 1$5001.:
1 _ 1 1, 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 thework 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.cpmpletion, the owner -builder will have the burden of proving that he or she did.not build or
.improve for the -.purpose of sale.). -
( I I, 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.).
( I I am exempt under Sec. - ,'BAP.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
Owner:
PGA WEST RESIDENCE 1 HOA
P.O.BOX 1060
LA QUINTA, CA 92253
Contractor:
EMERALD ROOFING INC
P.O. BOX 1963
PALM DESERT, CA 92261
(760)347-9869 "
Lic. No.: 770940
VOICE (760) 777-7012 .
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 9/28/07
WORKER'S COMPENSATION DECLARATION
I hereby. affirm under penalty of perjury one of the following declarations:
I have and will maintain 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,ofthe Labor
.'Gade, 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 639-0000108
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
3700 of the Labor Code, I shall forthwith comply with those provisions. '
Date: (b-1 - 6`7 Applicant:
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 ($100,0001. IN ADDITION 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, and hereby authorize representatives
of this county to enter upon the above-mentioned property for inspection purposes.
Date:IQ-1 -a-) Signature (Applicant or Agent);
Application Number . . .
Permit . . . RE -ROOF
Additional desc . .
Permit Fee . . . . 30.00
Issue Date . . . .
Expiration Date 3/26/08
07-00002618
Plan Check Fee .
Valuation . . .
Qty Unit Charge Per Extension
BASE FEE 30.00
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Special Notes and Comments
REROOF WITH FOAM SYSTEM
Fee summary Charged Paid Credited Due
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Permit Fee Total 30.00 .00 .00 30.00
Plan Check Total .00 .00 .00 .00
Grand Total 30.00 .00 .00 30.00
LQPERMIT