04-3616 (RR)eBU1LDING• &. SAFETY DEPARTMENT
P.O. Box 15,04 (7;60) 777=701-2
O 9 78-495 CArLLE_TAMPICo FAX (760),777=7011,
OF'I1�''. :.
LA .QUINTi�►. C ►LIFORMA .92253 INSPECTdON.;`RfEQUESTS (760) 777-7153_
A BUILDING PERMIT
Application -Number 4�0-0'0.03-6-16' Date 4'/21/04
Property Address 55730 PINEHURST
APNi -.775,,241
Application description.. RE-ROOF,,r;..
Prpperty,_ Zoning LOW:„DENS-hTY.- RESIDENTIAL
Application valuation `,g... .7500'
Owner Contractor
LA QUINTA PARTNERS OF MICHIGAN"''' '"EMERALD, ROOFING INC
2.8 0 0 NORTHWESTERN ' HWY . # 10 0 0' P. O :;::80X 19 6.3
S`OUTHFIELp ` PALM .:DESaERT CA. 92261
SEBRING`"FL 48075
WCC: ;STOVE INS -
'639108.04 01/01/05
CSLB: 7:70940 11/30/05
CCC:. C39.
•Permit RE -ROOF
Additional.desc
Permit Fee'-' .30-.00 .Plan Check Fee .00
Issue Date Valuation. 0
Qty Unit Charge Per Extensi6
BASE ::FEE 30.0,0
------------ 7 ---------- -- -- ----------------- --- ----------------
Spe,cial :Notes' and 'Comments. t
RE=ROOF WITH%POLYFOAM'
Fee.summary Charged Paid Credited: Due
-- - ---
71,
Permit.Pee Total 30.`00 :'0`0 •:00. 30..00
Plan Check Total 0.0 ..00 .00' .00
Grand Total. 30:,00 y '.00 00 30.00
3 tTR 2.6 2004,
... .: .kriFl L•M f�
P.O. Box 1504a � I VOICE (760) 777-7012
78-495 CALLS TAM►ICO A FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 44a
INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number.-3iv 1 Date:
Applicant:
Applicant's r . •N .
if
VIM
Architect or Engineer. -
Architect or Engineer's Address:
Lic. No.
BUILDING PERMIT DECLARATIONS
LICENSED CONTRACTOR'S DECLARATION
I hereby afrxm under penalty of perjury that I am licensed under provisions of Chapter 9 (Comnendng with section 7000) of Division 3 of the Business and ftlessionals
Code, and my -3h/ loroe and eRect Lice
D
License No. � ? [
DaltI am t
? 2 cion
1 hereby strum under penalty of perjury to OWNER -BUILDER DECLARATION
ell @n" from Ons Cw*uckxV Slab License Law for the following reason (Sec. 7031.6. Business and Prolessionc Code: Any
city or county that requires a permit b construct, spar. it pros. demolish, or repair any struWae. Prior b its issuance. also requires the applicant for the permit toss a signed
stslerno Out he or she k 6owo d pursuant b the povWww of the Contractus' Stab LJoeras Law (Chspbr 9 (Commencing with Section 7000) of Division 3 of the Business
and Professlons Code) or that he or she is exempt therefrom and the basis for ria aMged exemption. Any viciabon of Section 7031.5 by any applicant fora permit subjects
the applicant b a clivi penafy err not more tun fiva hundred k tars ($Stxi .r
U I, as owner of the property, or my employees with wages as their $ole compensation. will do the worts, and the slrucLrte is not trMended o offered for sale (Sea 7044.
Business and Professions Code: Thr. Corkradbrs• Slab License Law does not appy b on owner of property who builds or improves tnmean. and who does the wok
himself or herselt or trough his or her own employees, provided that the inprovanents are not Wended or offered for sale. it. however. the buidsg or inprovement k
sold within one year of completion. the owner4Ader will have the burden of proving tat he or she did not build or improve for the purpose of sok.).
(..) 1, as owner Of the property. am exdusivefy eontrading lath licensed contractors to construct the project (Sec- 7044. Business and Professions Code: The Contractors'
Stale License Law does not apply to an owner of property who builds or improves rieison, and who Contracts for the projects with a conftdor(s) licensed pursuant b
the ConeracbrV State License Law.).
(_) I am exempt under sea . B.& P.C. for Oils reason
Date Owner
1 hereby affirm under penalty of perjury one of theWORKERS
y COMPENSATION DECLARATION
I have and will maintain a certificate of conmt b sellknure for wakes'
of the work for whidn this petit is issued compensagion.
as provided ler by Section 3700 of the Labor Cade. lethe e pertorrnarnoe
I have and will maintain workers• compensation Lna,ranoe, as required by Section 3700 of the Lebo Code. fo the pedorn arnce of the work for which this penult k
issued . My workers' ns"
On tOxOnCe
Cartier and Policy number aro:
�rtier S I W rQ � S -.3c - Number
_ I certiy that, in the Performance of the work for which this pm* is issued. I shall mol
compensation hos of Carbaia, and agree that. if I should become employ any amp person in any manner so e io b3700 subject b the workers•
bNwft comply with terse provisions.subject b the woAcers' compensation provisions of section 3700 of the lobo Code.1 snot
WARNING: FAILURE TO SECURE WORKERS• COMPENSATION COVERAGE IS UNLAWFUL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (=100.000), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE. ONTEREST. AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
1 hereby aunder penalty of perjury Drat Overs k a constructionffirm
landing agency tot the performance of the work ler which this petit is issued (Sec. 3097. Civ. C.).
Lenders Name
Lenders Address
APPLICANT ACKNOWLEDGEMENT
IMPORTANT
Application Is hereby made to the Direcbr of Building and Safety for a Permit object b the conditions and restrictions set forth on tis applicglim
1. Exch person upon whose behaff this the owner. k made. each Person at whose request and for whose benefit work k performed under o pursuant b a
ny permit
Issued a result Of this epptication, the owner. and the apprcant, each agrees b, and shall, defend, indemnify and hold harmless the City of La O uhMs, its
agents and employees for any ad or omission related b the work being performed under or following issuance of this permit
2 Any Pon* issued as a result of this application becomes nun and void lfwok is not commenced within 190 dalys from date of issuance of such par.. or
cessation of work for 180 days will subject Petit 10 canceration.
Ico certify ftt I have av ��y� e n � a above informatw is correct, f agree b comply with as city and county ordinances and state saws retaking b building
tis county to enter upon the above-mentioned property ler inspection purposes.
Signature (Applicant or Agent