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05-0798 (RR)I _T4hf 4 4 a" BUILDING & SAFETY. DEPARTMENT x 1504 (760).777-7012 3ALLE TAMPICO FAX (760).777-7011 JTA', CALIFORNIA 92253 INSPECTION REQUESTS (760) 777-7153 P� BUILDING PERMIT App ion Number 05-00000798 f Date 3/Q9./05 perNotty Address .53845 AVENIDA VELASCO APN: 774-164-017-5 . -000000- Application description RE -ROOF ' Property Zoning•. . . . . . . COVE RESIDENTIAL - Application valuation 4800 Owner Contractor CASTILLO MARIO BIENEK ROOFING COMPANY 53845.AVENIDA VELASCO ,. 22622 LAMBERT STREET, #303 LA QUINTA CA 922.53LAKE.FOREST CA '92630 (949).951-3798 WCC: EXEMPT WC: EXEMPT 03/31/06 CSLB: 651509 07/31/06 CCC: C39 ----------------------------------------------------------------------.------ Permit . . . RE -ROOF Additional desc Permit Fee . . . . 30.00 Plan Check Fee*,. .00 'Issue Date . . . Valuation . . . . 0 ,Qty Unit Charge Per Extension BASE FEE 30.00 ---------------------------------------------------------------------------- Special Notes and Comments. REROOF WITH 30 YEAR COMP SHINGLES. CLASS "A" MATERIALS ONLY. Fee summary Charged Paid Credited Due Permit Fee Total 30.00 '.06 .00 30.00 Plan Check Total ..00� .00 .00 .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: a _- 0:2 Applicant: CO—_ Applicant's Mailing Address: Date: 1 - �j. - 9 Architect or Engineer: Architect or Engineer's Address: Lic. No.: BUILDING PERMIT DECLARATIONS LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals Code, and myLicP�sin f�Fiey�g�nd effect. ^ License Class 11 �� (_� 1 License No. 11 Date Contractor L:5�2� OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors' State 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 any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): U 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 Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does the work himself or herself or through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold within 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.). U 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 improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to the Contractors' State License Law.). U I am exempt under Sec. , BA P.C. for this reason Date Owner. WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. _ 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 insurance carrier and policy number are: Carrier Policy Number I certify that, in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Date <.aplicant WARNING: FAILURE TO SECURE WORKERS' COMP SATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 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 the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address 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 permit issued as a result of this application, the owner, and the applicant, each agrees to, and shall, defend, indemnify and hold harmless the City of La Ouinta, 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. Date Signature (Applicant or Agent): � 4 s 3. 4. 5. 6. 7. Business License No. SINESS LIC NSE APPLICATION FORM APPROVED BY DATE PROOF.OF WORKER'S COMPENSATION INSURANCE & COPY OF STATE CONTRACTORS LICENSE POCKET CARD IS REQUIRED PRIOR TO ISSUANCE Business.Name:' . n—'}��R'T Fn Business Address:,. i4A(0 `S• A-ve f City/State: ��@' C4 Zip: Mailing Address: 5A44,F as ABovE City/State: Zip: Business Phone: 874 - 2100 Owned By: CORP_ PARTNERSHIP INDIVIDUAL If Corporation or Partnership, Tax I.D. #: 3.30$533/ 2 -- Name of Owner or Officers and Title: k:�-n! MvoP. Er z 3,W t --t mv4.4 0 Vehicle License Number 'Permit Number (Finance Dept. Only) 8. Type of Contractor: B. Classification: ✓& C. State License Number` 69 /&S- A or B License Classification $100.00 Per Year or $50.00 Semi -Annual C License Classification $ 50.00 Per Year or $25.00 Semi -Annual I HEREBY CERTIFY that all the information supplied by me is correct and any licenses required by the. County. State or Federal Government have been issued -to me and are in full force and effect. A�eN � r-oiQ Signature' Title Date 03 O9 af" Send Completed Form To: CITY OF LA QUINTA BUSINESS LICENSE DIVISION P.O. BOX 1504' . La Quinta, CA 92247-1504