05-5009 (RR)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: 05-0000:50,0-9
Property Address: 55592. PINEHURST
APN: 775 -241 -006 -
Application description: RE -ROOF
Property Zoning: LOW DENSITY RESIDENTIAL
Application valuation: 295,39
Applicant:
T4hf 4.4 a"
Architect or Engineer:
I:)
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
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- LICENSED CONTRACTOR'S:DECLARATION .
I hereby affirm under penalty of perjury that 1. licensed under pr lions of pter 9 (commencing with
Section' 70001'of Division 3 of the Business and Professionals Cod nd my is nse is in full force and effect. '
Licensecl/ass: C39. _.L
ns 07707,
ate: / ���actor.
OWNER -BUILDER DECLARATION
I hereby affirm under.penalty of.perjury that I am exempt from the Contractor's State License Law for the
following reason ISec. 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, alsorequires the applicant for the
m
permit.to file a signed stateenfthat.he orshe is licensed pursuant:to.th'e provisions sof 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* 'permit subjects.the applicant to a civil penalty of not more "than five hundred dollars ($500).:
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
Contractors' State License Law does not apply to an owner. of property who builds. or improves thereon,
and who does the work'liimself or,herself through his or her own employees, provided that the
improvements are not intended or offered for sale. If, -however, the building of improvement is sold within
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.).
as owner ofifii property, amexclusively contracting with licensed contractors to construct the project ISec.
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.).
(_ 1 I am exempt under Sec. , B.&P.C. for this reason
Date: Owner:
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lendingagency 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 RESIDENTIAL HOA
54320 SOUTHERN HILLS
LA QUINTA, CA 92253
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 11/14/05
Contractor:
PETRONELLA ROOFING.COMPANY
68314 KIELEY ROAD NOV 1 [ 2005.
CATHEDRAL CITY,_CA 92234
(760) 3'24-5482 CITY�FIsA
Lic. No.: 460707 OF LA QUINTA
WORKER'S COMPENSATION DECLARATION '
hereby, affirm under penalty of perjury one of the following declarations:. _
have and will maintaina certificate of consent -iii self -insure for workers' compensation, as provided
for by Section 3700 of the Labor Code; for the performance of the work forjw6ich this permit is
issued
;
- kl have aril 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 workers' compensation
'insurance carrier and policy number are:, .. ,
Carrier STATE -FUND Policy Number 1801579
I certify that, in the performance of the work'for which this permit is issued, 1 shall not employ any
person in any manner so, as to become subject to the t -
o e rkers' compensation laws of California,
and agree that, if I should become subject to a w ' compensation provisions of Section
p'3700 of the Labor Code 1 sh l.fort eo I .. ith ose provisions.
,bate:
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 mioici;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 Directorof Building and Safety for a permit subject to the
conditions and restrictions set forth on this application.
1. Each person upon.whosebehalf 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.) have read this application and state that the above information is torr ct. I agree to comply with all
city and county' ordinances and state laws relating to building construction, and h r authorize representatives
" of this county to enter upon the above-mentioned property fo insp do s
ate: �'�^ e ��i ature (Applicant or Agent):
Application Number . . . . . 05-00005009
Permit . . RE -ROOF
Additional desc . .
Permit Fee . . . . 30.00
Issue Date . . .
Expiration Date 5/13/06
Plan Check Fee . . .00
Valuation . . . . 0
Qty Unit Charge Per Extension
BASE FEE 30.00
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Special Notes and Comments
RE -ROOF WITH POLYURETHANE FOAM SYSTEM.
INCLUDES 55-604 & 55-616.
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
LQPERMTT