07-0182 (RR)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
Property Address:
APN:
Application description:
Property2ohing:
Application valuation:
Applicant:
07-00000182
5-00-57 CALliE`OAXACA
773-340-029-29 -14496
RE -ROOF
LOW DENSITY RESIDENTIAL
3835
Architect or Engineer:
a/A
4
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Owner:
GISS VERNON J
33 PINEHURST CIR
LITTLE ROCK, AR 72212
Contractor:
WESTERN PACIFIC ROOFING CORP
3.4'62 LA CAMPANA WAY
PALM SPRINGS, CA 92262
(760)416-5877
Lic- No.: 235717
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 1/18/07
D. JZils
AN 291007 IUI
OF ! QUINTA
LICENSED CONTRACTOR'S DECLARATION
- ---- - - - - --
.WORKER'S COMPENSATION DECLARATION-
- I hereby affirm under'penalty of perjury that,l*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 lass B C39 License No.: 235717.
_
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
ate: �� ontractor: %i<ijrn; Ac•�4c iii+
issued.s
1 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
insurance carrier and policy number are:
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the
Carrier STATE .FUND - - Policy Number 046001635506• -
' 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 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
700 of the Labor Code,l alalll LQ hwitihh co/rr/lply h those provisions.
If
/t P
any applicant
aplicant for a permit subjects the applicant to a -civil penalty of not more than five hundred dollars (5500).:
ate: '� plicant: '- -
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
WARNI G: FAILURE TO SECURE 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.ownemployees, provided. that the
DOLLARS 1$100,000).1 IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
improvements are not intended or offered for gale. If, however, the building or improvement is sold within
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S .FEES.
one year ofPcompletion, the owner -builder will have the burden of proving that he or she did not build or
-
' improve for the purpose of sale.),
APPLICANT ACKNOWLEDGEMENT '
(_ I I, as owner of the property, am exclusively contracting with licensed contractors to construct the project ISec.
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the
7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of
conditions and restrictionsset forth on this application.
property who builds or improves thereon, and who contracts for the projects with a contractorls) licensed •'
1 . Each person upon whose behalf this application is made, each person at whose request and for
pursuant to the Contractors' State License Law.). ' -
whose benefit work is performed under or pursuant to any permit issued as aresult of this application,
(_) I am exempt under Sec. , B.&P.C. for this reason
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.
Date: Owner:
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 suchpermit, or cessation of work for 180 days will subject
- CONSTRUCTION LENDING AGENCY
permit to cancellation.
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the
I certify that I have read this application and state that the above information is correct. I agree to comply with all
work for which this permit is issued (Sec. 3097, Civ. C.I.
city and co ty ordinan/andto laws relating to building constructionyyVand hereby authorize representatives
'
Name; -
of this my to enter ove•mentioned property for i pec
n p rpose�Lender's
D e: a r/ Siplicant or Agent):
Lender's Address:
LQPERMiT
qvw_1,4y
Application Number . . . . . 07-00000182
Permit RE -ROOF
Additional desc .
Permit Fee . . . . 30.00
Plan Check
Fee
.00
Issue Date . . . .
Valuation
. . .
. 0
Expiration Date . . 7/17/07
Qty Unit Charge Per
Extension
BASE FEE
30.00
----------------------------------------------------------------------------
Special Notes and Comments
REMOVE EXISTING TILES & INSTALL NEW
UNDERLAYMENT. REPLACE ORIGINAL TILES
Fee summary Charged Paid
---------------------------
Credited
Due
----------
Permit Fee Total 30.00
----------
.0c
----------
.00
30.00
.Plan Check Total .00
.00
.00
.00
Grand Total 30.00
.00
.00
30.00
LQPERAIIT