07-0176 (RR)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
X0_7=000.0.0.16��
Property Address:
5.0_077—CAL-L-E' GAXACA
APN:
773-340-027-27 -14496
Application description:
RE -ROOF
Property Zoning:
LOW DENSITY RESIDENTIAL
Application valuation:
3770
Applicant:
Architect or Engineer:
PIP
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Owner: .
FRISBY MARK A
12909 167TH AVE NE
REDMOND, WA 98052
Contractor:
WESTERN PACIFIC ROOFING CORP
3462 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 Q
JAN 2 9 2007 .
CITY.OF LA QUINTA
FINANCE DEPT.
---=---------------------------------------------
LICENSED CONTRACTOR'S DECLARATION
-
----------------------------------------------—
WORKER'S COMPENSATION DECLARATION +r
I hereby affirm under penalty of perjury that I am licensed under %.provisions of.Ch'6pter 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
Licen_ sl, Class: B C39 License N6.:' 23571.7 -
)
_
for by Section 3700 of the Labor. Code,. for. the performance of the work for which this permit is
issued..
ate: �Li,Contractor: f(/�JTr/n /'4!c gg;4,- le oe.
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 workerscompensation
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
.- 700 of the abor Code, -1 s allefo comply wi those provisions.
that he or she is exempt therefrom and the basis for the alleged.exemption. Any violation of Section 7631.5 by
a
-
[f+7
anyapplicant for a permit subjects the applicant to civil penalty of not more than five hundred dollars (55001.:
_I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and
ate: plicant: ,
the structure -is not intended or offered for sale (Sec. 7044,rBusiriess and Professions Code: The ..
WARNING: 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 own employees, provided that the ' f
DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
improvements are not intended or offeredfor sale:. If, however, the building or improvement is sold within
SECTION 3706 OF THELABOR 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.).
- APPLICANT ACKNOWLEDGEMENT
(_ 1 1, as owner of the property, am exclusively contracting with licensed contractors to construct the,project (Sec.
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 restrictions set forth on this application.
property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed
1. Each person upon whose behalf this application is made, each person jet whose request and for
pursuant to the Contractors' State License Law.).
whose benefit work is performed under or pursuant to any permit issued as a result of this application,
(_ 1 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. ..
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
of La Quinta, its officers, agents and employees for any actor 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 a county ordinances and state laws relating to building construction, and hereby authorize representatives
of t�counI enter upon he above-mentioned property for ' spection. ur /es. /
ab te:7Z S' ature (Applicant or Agent):
��lN�
Application Number . . . . . 07-00000176
Permit . . . RE -ROOF
Additional desc . .
Permit Fee . . . . 30.00
Issue Date . . . .
Expiration Date . . 7/17/07
Plan Check Fee . . .00
Valuation . . . . 0
Qty Unit Charge Per Extension
BASE FEE 30.00
----------------------------------------------------------------------------
Sp&cial Notes and Comments
REMOVE EXISTING TILES & INSTALL NEW
UNDERLAYMENT. REPLACE ORIGINAL TILES
Fee summary Charged Paid Credited Due
---------------------------------------------------------
Permit Fee Total 30.00 .00 .00 30.00
Plan Check Total .00 .00 .00 .00
Grand Total 30.00 .00 .00 30.00
LQPERMIT