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07-0178 (RR)P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 Application Number: 07-00000178 Property Address: 50097 CALLE OAXACA APN: 773-340-025-25 -14496 Application description: RE -ROOF Property Zoning: LOW DENSITY RESIDENTIAL Application valuation: 3770 / I - BUILDING & SAFETY DEPARTMENT BUILDING PERMIT Owner: ELLINGSON DARRYL E 1713 BRUSH CREEK RD SANTA ROSA, CA 95404 VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 1/18/07 Contractor: Applicant: Architect or Engineer: WESTERN PACIFIC ROOFING CO 3462 LA CAMPANA WAY JAN 2 9 2007 PALM SPRINGS, CA 92262 (760) 416-5877 CITyOF Lic. No.: 235717 F1 IF E Q�INTq DEPT, 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 `� issued. /Date:. Z' •7Xntractor: /�Y/J Tti,. •�LI H,�. ��s_.Y _ VAI have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor —FFF-" 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 . - 3700 of the Labor Code; all h ith com I it hose provisions. 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 ($500).: ate ' o A cant: (_) 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and, .the structureis not intended or offered for sale (Sec. 7044, Business and Professions Code: The WARN(NG: FAIL RE 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 DOLLARS ($100,000). -IN ADDITIONTO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN improvements are not intended 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.).- APPLICANT ACKNOWLEDGEMENT ( 1 I, as owner of the property, amexclusively-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. propertywhobuilds 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 at whose request and for puisuant 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 _ 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 I 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: LQPEPAIIT ff oLa Qumta, its oicers, 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 coty ordinances and state laws relating to building construction, and her by orize representatives of this /I/, my [ enter upon a above-mentioned property for ' sp on rpose D e: 07 S' nature (Applicant or Agent): Application Number 07-00000178 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 ----------=--------------7-------------------------------------------------- BASE FEE 30.00 Special Notes -and -Comments REMOVE EXISTING TILES & INSTALL NEW UNDERLAYMENT. REPLACE ORIGINAL TILES Pee summary Charged Paid, Credited Due Permit Pee Total ------- 30.00 ---------- :00 ---------- .00 30.00 Plan Check Total .00' .00 .00 .00 Grand Total 30.0,0 .00 .00 30.00 LQPERDIIT