04-3580 (RR)BUILDING•& SAFETY DEPARTMENT
c - P.O..Box 15.04 (760) 777-7012
OFTt�'9 78-495 CALLS TAMPICOFAX (760).777-701.1
LA.- .Q.U1NTA. U6F0RN.IA 92253 INSPECTION :REQUESTS (760)-777-7153
BUILDING PERMIT
Application Number :014-0000358-6�� "' Da'te 4/1.9/04
Property Address . . . *:55670 'PINEHUR'ST
APN: 775 -241 -'009 -
Application description.,:. b RE. -_-ROOF•
Property Zoning' LOW'DENSITY RESIDENTIAL
Application Valuation 35,00,
Owner Contractor
-- -=
WHITE, TRAVIS E/JANICE C EMERALD ROOFING INC
5567.0 PINEHURST P:O,:'BOX 1963
LA QUINTA CA 9;225'3 PALM' DESERT. CA 92261
: WCC : STOVE INS
WC. 63910804 01/01/05
CSLB `, 7,7'09:40 11/30/05
CCC;"'. C3 9
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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
------------------ ----Special Notes and Comments
RE -ROOF WITH, POLY'FOAM
Fee summary Charged Paid. Credited. Due
------------------- -- ------------.. - - ----
Permit Fee Total 30.00 .00, ..00 .30.00
Plan Check;i. Total 00 X00{ 00 .00.
Grand.Total 30.00 :0:0 .00 30_.00
�.� R 2 6 20034 zLj
P.O. Box 1504 UWA
VOICE (760) 777-7012
78-495 CALLE TAMPICD FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 Ot 4 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number:j4 ',3. Date:
Applicant:
Applicant's Mailing Address:
Architect or Engineer.
Architect or Engineer's Address:
K! A—
Lic. No..
BUILDING PERMIT DECLARATIONS
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under Penalty of pe*" that 1 am licensed hander provisions Of Chapter 9 (Commencing wtth section 7000) of Division 3 of the Business and Pnolessionsls
Code. and my is in U force and effect.
.4ioense Class ---- License No. `) 7 o q,.-[ d
-G1-7
r-
1 hereby afram under OWNER-BUtL.DER DECLARATION
ICY a PAY that I am exempt tram Core CormackxV Stale License Law for the fobwing reason (Sec. 7031.5. Bra kuru and Professions Code: Any
Y e Comha bat a Permit b constrhrc, altar, over. demolish or repamr any strurabM Prior b Its issuance. also requires the applicant for the permit b fie a spored
ebtertherrt that he a she le icerhsed Pursuant b the provisions Of the Conbactors' Slate License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business
and Praessknu Code) Or that he Or she Is exempt bersfinrn and the basis for the aaeged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects
the applicant to a civil penally of not mere Cyan five hundred dollars 4500).):
U I, as owner of the Property. or my employees with wa, as their SC6e 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 appy to an owner a Property who bolds or improves Chereor► and who aces the wank
sold i or herself y a ofcothrough his a her owner jildem, provided that Cin improvements are not intended or offered for sale. If. however. the bu&kV or improvement is
U sold within the y. m exclusively
n. the owner -bidder will have the burden of a proving Out he or she did not build or improve for the purpose of sale.).
(. as owns a the contracting of P h licensed contractors b construct the project (Sea 7044, Business and Professlom Code: The Contractors'
State License Law does not apply b an owner a property who builds or improves thernorh and who contracts for the projects with a contracto(s) licensed pursuant b
Che Contractors' State License Law.).
U I am exempt under Sec. . B.& P.C. for this reason
Date Owner
1 hereby affirm under penalty of perjury one of the following deWORKERS' COMPENSATION DECLARATION
dardbors:
1 have and will maintain a certificate agent to selrinswe for workers' compensation, as provided for by Section 3700 of the Labor Code. for the performance
a the work forwhich Cris pe . Is issued
/- I have and will maintain wakes' compensation insurence as required by Section 3700 of the Labor Code, for the performance of the work for wlid ors permil is
/
wo
ST` carrier and policy number are:
nber
�.amer c� e-� [
/ I certify bel, in the pertonrrhance' the work forma which this permit is issued. l shall not employ any person in any manner so as to become subject to the workers'
compensation ation laws of California, and epee that. Y subject D i should became sthe workers' Compensation provisions a a Section 3700 the Labor Coda. l shall
Comply with those provisions,
WARNING: FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENAL TIES AND
CIVIL FINES LIP TO ONE HUNDRED THOUSm DOLLARS (5100.000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR TI
SECTION 370!3 OF THE LABOR COOS. N�ITEREST, AND ATTORNEYS FEES. .IN
1 hereby affirm under penally of pejury that thereis a oonstrhxtiom CONSTRUCTION LENDING AGENCY
lending agency for the Performance Of the work for which On permit is issued (Sec. 3097. Civ. C.).
Lenders Name
Lenders Address
IMPORTANT Application Is APPLICANT ACKNOWLEDGEMENT
hereby made b the Director a Building and Safety for a.permit subject to the ccr eons and restrictions set forth on this appicafim
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 shad. defend. indemnity and hold harmless the City of Le Oukda, its
officers, agents and employees for any ad or omission related to the work beteg performed under or following issuance of this permit.
2 Any perm -tion issued or s result s this application becomes null and void x work is not commenced within 160 days from date of Issuance a such Penn' or
certify
cessation a work for 160 days w81 subject permit b cancellation.
icautry that I have and he d this aPpicabon and state that the above Information 3s correct I agree b Comply with ap city and county ordinances and state laws relating b building
retry authorize representatives of this cantly to enter upon the above-mentioned property for inspection purposes.
Signature (Applicant a