12-0626 (RR)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
T4'!t � °F 4 Q"
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 6/06/12
Application Number: S12=0000� Owner:
Property Address: 52400 AVENIDA VALLEJO GB INLAND PROPERTIES II
APN: 773-263-008-15 -000000- 110 N. LINCOLN AVE #100
Application description: RE -ROOF CORONA, CA 92.882
Property Zoning: COVE RESIDENTIAL
Application valuation: 4200 tJ��t
Contractor:
Applicant: Architect or Engineer: RWIr INC' ^tee i
3401 GATO COURT N V r�12
RIVERSIDE, CA 92507 CiTY'OF
(951) 328-0096
il— -ALeUiNi�q
/P r Lic: No.: 968418
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 ofperjuryone 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 'cense No.: 968418 for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
issued.
Date:o Ctractor: 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
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 Numbei 1959931-2012
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 �Mhwith co p wwith those provisions.
that p li she o exempt therefrom and the cant t or the alleged exemption. Any violation d Section 7031.5 by :any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).: Date: pplicant:
(_) 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: 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 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.).
(_) 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 contractors) licensed
pursuant to the Contractors' State License Law.).
I—) 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: '
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.
1 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 bu'Idin con rrc�ttion, and hereby, authorize representatives
of this
�county
/tt�oienter upon the above-mentioned prop or ctid purposes
S' atura (Applicant or Agent):
LQPERMIT
Application Number . . . . . 12-00000626
Permit' . . . RE -ROOF
Additional desc .
Permit.Fee 30.00
Plan Check -Fee -.
.00 -
Issue Date . . . .
Valuation
0
Expiration Date 12/03/12
Qty Unit Charge Per
Extension
BASE FEE
30.00
----------------------------------.-------------------.-----------------------
Special Notes and Comments
REMOVE EXISTING TILE, ADD NEW 30 LB.
ASTM UNDERLAYMENT THEN RE -INSTALL
EXISTING TILE'. 2010 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 .0.0
.00 .00
.00
Other Fee Total 1.00
00 .00
1.00
Grand Total 31.00
.00 .00
31.00
LQPERMIT
Bfn.#
Qty Of .La Quinta
BuffdQlg 8r Safety Division
P.O Box 1504,-78-495 Caffe Tampico
1A.Quin4 CA 92253 • x(760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
Project Address: e O
i4 E
Owner's Name:( +,a I Pr •
A P. Number.
Address
Icily,
Legal D tion:
ST, Zip:
Contractor. iQ LIIX
G°
Telephone: ^-� (aC7
Address:
Project Description:
City, ST, Zip:tlmuow
Telephone: —
State Lie. #: Q B
Atdh„ EW., Designer
2 c6-0 % e �'
tjv��j � .
S �Y
Address.
City, ST, Zip:
Telephone:
State Lia #:
Construedon Type: �—� occupancy: s i
Project type (circle one): New Add'n Alter Repair Demo
Sq. Ft.: g # Storids: # un*
Name of Contact Person:
Telephone # of Contact Person:
Estimated Value, of Project H
APPLICANT: DO NOT WRITE BELOW THIS UNE
#
SubmltW
RtVd
need TBACMG
PERMIT FEES
Paan Sets
Pian Check submitted •
Item Amo+mt
Structural Cake.
Reviewed, ready for correcdoes .
Pian Check Deposit. .
TtVIs Caks.
Calitd Contact Person
Pbn Chedr Balance.
Tide 24 Cales,
Plane picked up
Constractlon
Flood plain pine
Plans resnbmtft d. ,
Me¢harikat
Grading plan
tad Review, ready for correctionsressue
Electrical
Subeontaetor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
&MJL
H.O.A. Approval
Pians resabmtf d
Gradlag
W HOUSE.-
''" Review; may for eorresf ineasae
Developer Impact Fee
Planning Approval •
Called Contact Person
Pub. Wks. Appr
Date of permit issue
SdwW Fees
Total Permit Fees