11-1059 (RR)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
Property Address:
APN: "
Application description:
Property Zoning:
Application valuation:
0000(05.
54123 SOUTHERN HILLS
.7757101-042- - -
RE -ROOF
LOW DENSITY RESIDENTIAL
.13000
BUILDING & SAFETY DEPARTMENT
BUILDING •PERMIT
r Owner:
i PGA HOA
54320 SOUTHERN HILLS
LA QUINTA, CA 92253
Contractor:
c
l
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7.153
Date: 9/29/11
Architect or Engineer.
BRS ROOFING INC 1'Applicant: T .
465 S._ LUGO_
SAN BERNARDINO, CA 92408 Cl�rOF,i
'QUINTA
Iy
(909) 496-3113
FIP4 A� E D;PF
Lic. No.: 907600
'l
+
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- LICENSED CONTRACTOR'S DECLARATION'
_ WORKER'S COMPENSATION DECLARATION
- I hereby affirmunderpenalty 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 Professions ode, 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: C3 9 07600
for by'Section 3700 of the Labor Code, for the performance of the work for which this permit is
-Licen
- - - _
ate: Es mractor: - - -
�% issued.
0.1 have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor
i_ 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 penaltyof 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 becom-0.9 he workers' compensation provisions of Section
License Law (Chapter 9 (commencing with Section 70001 of Division 3 of the Business and Professions Code) or
3700 of the Labor Co_ de, I shall forth comp y e provisions. -
that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
��1 A
any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
e:l� cant: .
(_ 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
WARNING: FAILUR T URE 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 15100,000)• IN ADDITION TO 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, 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 ismade, 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 a result 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 such permit, 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 abov 'information is correct. I agree to comply with all
work for which -this permit is issued ISec. 3097-, Civ. C.1.
city and county ordinances and state laws relating to building cons and hereby authorize representatives
- -
of this county to enter upon the above-mentioned operty for ins ction.pur S. -
_ -
Lender's Name:
6 �� / ( - -
• ' ' -
- Sign re (Applicant or Agentl. .'
Lender's Address:
J000,�e
LQPERMIT W
E.
Application Number . . . . 11-00001059
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.. 201.0.
CODES,.
----------------------
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
i.00 .00
.00*
1-00
Grand.Total
31.00 .00
.00
31.00`
LQPERMIT -