04-3624 (RR)-BUILDING &. SAFETY DEPARTMENT
P.O..BOX 1504
(7.60).777=7012
OF 9. 78-495:CALLE;TAMPICo
760).777 -7011 -'
FAX (760 -Y.777 -7011-
A.'
LA Q:UINTA, CA tFORN.I� 92253. INSPECTION,REQUESTS (760)-777-7153
BUILDING PERMIT
.Application.Number
04-00003624 Date 4/21/04
-Property Address'
55970.PINEHURST
APN:775-241-020,'h..
- -
Application description..
RE -ROOF,,
Property: Zoning .. . '
LOW DENSITY' -RESIDENTIAL.
Application valuation '.
7.500`
-Owner
Contractor
GRODEN ALFREDT /DARLEEN
------------------------
EMERALD/ROOFING_ INC
131:4 . MULBERRY . RD
P': O ..,,.BOX...1<963
MARTINSVILLE Vk 24112
_PALM'.pESERTr.: CA 92.261
STOVE INS . -
WC. 6.39 :0804 01/01/05
,.- ..
..CS:LB: - �77094�0:. - -. 11/30/.05
C3 9
_�---------=-------- -- - ---------
----------- - --- ---------------------
Permit RE -ROOF
-
-Additional`-:desc
Permit Fee 3.0:00
Plan Check Fee.. .00
Issue Date`
Valuation 0
Qty Unit Charge Per
Extension
BASE FEE 3 0°: 0.0
Speci-a1 `�Not*es, and :Comments
RE - ROO:F . WITH. POLYFOAM
Fee- summary Charged
----
_: Paid. Credited -.Due'-
.Due` °
Permit. Fee °-Total 30.;00
j . . . 0
::00: .30..0
Plan':Check Total ; 00:
0;0 . 0.0 . .: 00
Grand Total 30.00
.00- ..00 30.00
P.O. Box 1504
VOICE (760) 777.7012
78-495 CALLE TAMPICO FAX .(760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number. �� -.(oa Date:
Applicant: Architect or Engineer.
Applicant's Wiling Address: Architect or Engineer's Address:
Lic. No.:
BUILDING PERMIT DECLARATIONS .
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of palmy toad am licensed under rovisions of chapter t (M menanp with Sectioi 7000) of Division 3 of the Business and Prolessionnk
and my License is in tone and affect
License No. ? -? O Q q
p a) _�5;
OWNER43UR DER DECLARATION
I hereby affirm finder penally of perjury that I an exempt from the Contractors' Stals License Law for the following reason (Sec. 7031.6. Business and Processions Code: Any
city or county that requires a permit b construct alter. improve. demolish, or repair any structure, prior b its issuance. also requires the applicant for to permit to fila a signed
ctalerna drat he or she is ioensed pursuant lb the provisions of the Contraclos' state License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Bustrim
and Professions Code) or that he or she is exempt themfaom and ft basis for the aitaged exenmption. Any violation of Section 7031.5 by any aoP fa a permit subjects
the applicant b a civil penally of not more than live Modred dollars (t500).r
U I. as owner of the property, or my employees with wages as their sole compensaGm wiN do the work, and the structure is not intended or offered for tale (Sec. 7044..
Business and Professions Code: The Carhtraclors' State License Law does not appy to an owner of propertywhho builds or improves thereon; and who does the work
hirgseff or herself or through his or her own employees, provided that the irproverne-ft are not Intended or offered for sale. If. however, the ar
sold wti in one year of completion; the owner-biAder.w� have the burden of proving that he or she did not build or improve tar the purpose of M a
U Las owner of.the property. am exclusively contracting with ioersed contractors to construct Che project (Sec. 7044, Business and Protessiaa Code: TheContractors!
State License Law does not appy to an owner of property who builds or improves thaeon, and who contracts for the projects with a comtracton(s) licensed pursuant to
the Contractors' State License Law.).
U I am exempt under Sec. _ , . BA P.C. for tis reason
Date. Owner
1 hereaffirm under WORKERS' COMPENSATION DECLARATION
by Penalty of Pedury oma of the fonowhng declarations:
_ I have and will maintain a certificate of consent b seC.bhsme for workers' compensatim as provided for by Section 3700 of the Labor Code. for the performance
of the work for which this perit is issued.
I have and will maintain workers• compensation insurance, as required by section 37M of the Labor Code. for the performance of the work for "lid ok permit is
issued. My wo"' compensation I nuance carrier and policy number are:
S Ti•4-tom . t�� .,,,,..
_ I certify that in the performance afthe work for vrtiicA this pemxt is issued. I shah not tsnploy any person In any manner so as to become subject b the wokeW
compensation laws of Caifomla, and agree Chat lf I should become subject b the wokere compensation provisions of Section 3700 of the tabor Code. I shall
fort wItn.complywith arose provisions.
=Z6
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLA AND SHALL S' UBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CML FINES UP TO ONE.FMdDRED THOLWM DOLLARS (=100.000). IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES. .
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for that performance of the work for which this permit is Issued (Sec. 3097. Civ. C.).
'L~s Name
Lender's Address
APPUCA1 T 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 appicatim
1. Each Penson upon whose behalf this application is made. each Penson at.whhose request and for whose benefit wok is perto red under or pursuant to any peril
Issued as a result d this applicatim the owner, and ria applicant, each agrees b. and shhail, defend. Indemnify and hold harmless the City of La Oulnta. its
officers. agents and employees for any act or omission related to the work being performed under or following issuance or this Permit.
2. any Permit Issued as a result of tis application becomes nun and void lf wok is not commenced within 160 days from date of issuance of such permit, or
cessation of work for 180 days wilt subject permit to cancellation.
I cerw that I have read this application and state that the above information is torted. 1 agree to comply with ail city and county ordinances and state laws relating to building
construction. and hereby authorize representatives of this county to enter
. upon the above-rmentioned property for Inspection purposes. .
,G Signature (Applicant or Agent):