11-1063 (RR)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: 11-00001063
Property Address: 54744,ySHOAL CREEK
APN: 775-071-057- -
Application description:RE-ROOF
Property Zoning:
Application valuation:
Applicant:
13000
75b, 5y=7b�� sy-�80
-^� VOICE (760) 777-7012
ceuv000, 4` FAX (760) 777-70.11
BUILDING & SAFETY DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING -PERMIT
Date: 9/29/11
Owner:
PGA HOA
- 54320 SOUTHERN HILLS
LA QUINTA,, CA 92253
Architect or Engineer:
Contractor: IPF007rT
BRS ROOFING INC
465 S. LUGOu Ov 2 11 I'll
SAN'BERNARDINO, CA 924 8
(909) 496-3113 CITY OF!�►4hi1!lVTi4
/ Lic . No.: 907600 FINANCE Drpr
�L� -
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: C39 - Licens 07600 for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
i / / - - issued.
ate: ractor: El I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor
l T'� Code, for the performance of the work for which this permit is issued. My workers' compensation '
OWNER -BUILDER DECLARATIONinsurance 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 238403010
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 suto 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, I shall forthwit r com those 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.dolla[s ($.500).:__.____ ..
(_ 1. 1, as owner, of the property, or my employees with wages as their sole compensation, will do the work, and T
the structure is not intended or offered for sale (Sec. 7044, Business 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 DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
improvements are notintendedor offered for sale. 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.).
(_ 1 I, as owner of the property, am exclusively contracting with licensed contractors to construct theproject(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.).
(_) 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: Ik
n
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 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 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. 1 agree to comply with all
city and county. ordinances and state laws relating to building construction, and hereby authorize representatives
of this county to center upon the above-mentionedroperty for inspection purpos r^/
11rfw: /'L% J ;gnature (Applicant or Agent
Application Number . . . . . 11-00001063
Permit RE -ROOF
Additional desc
Permit Fee . . . . 30.00 Plan Check
Fee
.00
Issue Date . . .'. Valuation
0
Expiration Date 3/27/12
Qty Unit Charge Per
Extension
BASE FEE
30.00
Special Notes and Comments
SWEEP GRAVEL THEN APPLY COOL ROOF RATED
POLYURETHANE FOAM ROOF SYSTEM. 2010
CODES. INCLUDES ADDRESSES 54-756; 54-768
& 54-780.
-----------------_-_-------------------------
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
LQPERMIT