09-0193 (RR)� � tom•'
P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
Property Address:
APN:
Application description:
Property Zoning:
Application valuation:
Applicant:
X09-00000'193==::�
50005 CALLE ROSARITA
658-250-041- -
RE -ROOF
.LOW DENSITY RESIDENTIAL
17600
T,&t
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BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Architect or Engineer:
Owner-
SANTA
wnerSANTA ROSA COVE HOA
P.O. BOX 12920
PALM DESERT, CA 92255.
Contractor:
WESTERN PACIFIC ROOFING
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 3/02/09
a r
MAR 0 4 9nnn III
•
3462 LA CAMPANA WAY
PALM SPRINGS, CA 92262 ClTygF 4rl
\
(760)4-
165877 r ,-'iA/47�
Fd.1.3`t r T
Lic. No.: 235717
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' LICENSED CONTRACTOR'S DECLARATION
• WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with
I hereby affirm under penalty of perjury one of the following declarations:
Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect.-
I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided
License Class: B C39 License No.: 235717
_
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
7 _
/K1e:1'6ontractor: �� (,.�- �4��
issued.
Y� I have and 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
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the
insurance carrier and policy number are:
Carrier CYPRESS INS Policy Number 33000053308081
following reason (Sec. 7031 .5, Business and Professions Code: Any city or county that requires a permit to_
I certify that, in the performance of the work for which this permit is issued, I shall not employ any
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the
person in any manner so as to become subject to the workers' compensation laws of California,
permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State
- and agree that, if I should become subject to the workers' compensation provisions of Section
License Law (Chapter 9 (commencing with Section 7000) of Division 3 o the Business and Professions Code) or
3700 of the Labor Code, I shall forthwith comply with those ovisions.
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 (55001.:
Ste: �'—�cant:1,
XTOPSECURE
as owner of the property, or my employees with wages as their sole compensation, will do the work, andthe
structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The
WARNING: FAIL RE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
Contractors' State License Law does not apply to an owner of property who builds or improves thereon,
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
and who does the work himself or herself through his or her own employees, provided that the
DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
. improvements arenotintended or offered for sale. If, however, the building or improvement is sold within
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. '
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.). '
( _) 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.improvoe thereon, and who contracts for the prnjects with a contractorls) licensed
pursuant to the Contractors' State License Law.)
(_ f _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 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
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 peimit issued as a result of this opplication,
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.
J
ignature (Applicant or Agent)L
Application Number 09-00000193
Permit . . . RE -ROOF
Additional desc .
Permit Fee . . . 30.00
Plan Check Fee
.00
Issue Date . . . .
Valuation . . .
. 0
Expiration Date 8/29/09
Qty Unit Charge Per
Extension
BASE FEE
----------------------------------------------------------
30.00
Special Notes and Comments
-------------------
INSTALLATION OF NEW TILE UNDERLAYMENT.
INCLUDES ADDRESSES: 50-015, 50-025,
50-035.
--------------------------------------- ---------------------- 7 ----------------
' Other Fees . . . . . . . . . BLDG STDS ADMIN (SB1473)
.
1.00'
Fee summary Charged Paid
Credited
Due
---- ----------
Permit Fee Total 30.00
---------- -_---------
.00 .00
30.00
Plan Check Total .00
.00 .00
.00
Other Fee Total 1.00
.00 .00
1.00
Grand Total 31.00
.00 .00'
31.00