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11-0589 (RR)P.O. BOX 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT BUILDING PERMIT + Owner: SANTA ROSA COVE HOA PO BOX 12920 PALM DESERT, CA 92255 VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153° Date: 6/06/11 Contractor: �X G``� Applicant: Architect or Engineer: WESTERN PACIFIC ROOFINGNOR 3462 LA CAMPANA WAY PALM SPRINGS CA 92262 (760)416-5877 Lic. No.: 235717 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 I B C3 9 License No.: 5717 for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ate: GG I ntractor: 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 ZURICH AMERICAN Policy Number WC672422800 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, 1 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; I sha o it comply ith, se 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 1$5001.: Date:G //ZESECnt: - (_ 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: FAILURE 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 1$100,0001. 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 ' 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 .. 7044,8 usness and Professions Code: The Contractors' State License Law does not apply town 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 is made, 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 . fL O' ff' d I II d h kb 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 (Seca 3097, Civ. C.). Lender's Name: Lender's Address: LQPERMIT i o a uinta, its o kers, agents an emp oyees or any act or omission re ate tot a wor eng 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 1,80 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 o/f/thrs cou y t enter upon he above-mentioned property for i pection /qurposes D .. - � ate: ` �/ nature (Applicant or. Agent Application Number: r11-000005 9 ;.-. Property Address: 49274 AVENDA VISTA BONITA I APN: 773'-350-022-22 -14496 - Application description: RE -ROOF. Property Zoning: LOW DENSITY RESIDENTIAL Application valuation: - 13475 BUILDING & SAFETY DEPARTMENT BUILDING PERMIT + Owner: SANTA ROSA COVE HOA PO BOX 12920 PALM DESERT, CA 92255 VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153° Date: 6/06/11 Contractor: �X G``� Applicant: Architect or Engineer: WESTERN PACIFIC ROOFINGNOR 3462 LA CAMPANA WAY PALM SPRINGS CA 92262 (760)416-5877 Lic. No.: 235717 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 I B C3 9 License No.: 5717 for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ate: GG I ntractor: 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 ZURICH AMERICAN Policy Number WC672422800 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, 1 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; I sha o it comply ith, se 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 1$5001.: Date:G //ZESECnt: - (_ 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: FAILURE 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 1$100,0001. 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 ' 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 .. 7044,8 usness and Professions Code: The Contractors' State License Law does not apply town 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 is made, 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 . fL O' ff' d I II d h kb 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 (Seca 3097, Civ. C.). Lender's Name: Lender's Address: LQPERMIT i o a uinta, its o kers, agents an emp oyees or any act or omission re ate tot a wor eng 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 1,80 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 o/f/thrs cou y t enter upon he above-mentioned property for i pection /qurposes D .. - � ate: ` �/ nature (Applicant or. Agent Application Number 11-00000589. Permit RE -ROOF Additional desc Permit Fee . . 30.00 Plan Check Fee .00 Issue Date . . . Valuation . . 0 Expiration Date 12/03/11 Qty Unit Charge Per Extension BASE .FEE 30.00 Special Notes and Comments TAKE OFF EXI3TING TILD, IITGTP.LL NEW UNDERLAYMENT & REPLACE.ORIGINAL TILE. INCLUDED UNITS AT 49-294 & 49-312. 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 .00 00 .00 .00 Other Fee Total 1.00 .00 .00 1.00 Grand Total 31.00.00 00 31.00 LQPERMIT .,