09-0182 (RR)P.O. BOX 1504
78-495. CALLE TAMPICO
LA QUINTA;,CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT,..
BUILDING PERMIT
Application Number:{ 09-000,00182 f "
Property Address: _ 49921 AVENIDA VISTA BONITA
APN: - 1 773-340-077-140 -14496 -
Application description: RE -ROOF
Property Zoning: LOW DENSITY RESIDENTIAL
Appliootion voluotionl - 24475 I
Applicant: Architect or Engineer
VOICE (760) 777-7012
FAX (760) 777 -7011 -
INSPECTIONS (760) 777-7153
" LICENSED CONTRACTOR'S DECLARATION
----------
WORKER'S COMPENSATION DECLARATION "
Date: "3/02/09
I hereby affirm under penalty of perjury one of the following declarations:
Owner:
..
I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided
. License Class: B C39 - License No.: 23 5717.
SANTA ROSA COVE
HOA
,ate: �2�� 1 ontractor: /�/(,/
P.O. BOX 12920
-
PALM DESERT, CA
92255
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
D/d1
a
Contractor:
_ 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
ESTERN PACIFIC
ROOFING CORP
and agree that, if I should become subject to the workers' compensation provisions of Section
3462 LA CAMPANA"WAY
MARo`�
20U9
PALM SPRINGS, CA
92262
any applicant for a.permit subjects the applicant to a civil penalty,of not more than five hundred dollars ($500).:
9+
(760)416-5877
1—) I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and
CITYOF
TY F LA QUiNTA
-
Lic. No.: 235717
" LICENSED CONTRACTOR'S DECLARATION
----------
WORKER'S COMPENSATION DECLARATION "
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: B C39 - License No.: 23 5717.
_
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
,ate: �2�� 1 ontractor: /�/(,/
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
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 CYPRESS INS Policy Number 33000053308081
' following reason (Sec. 7031.5, Business and Professions Code: Anycity 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 Labor Code, I shall forthwith comply with 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 dollars ($500).:
-0 pplicant:
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 ISec. 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 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
1, 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 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,
1 _ 1 I am exempt under Sec. ,8.&P.C. for this reason. -
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. -
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. ,
hereby affirm under penalty of perjury thatthere is a construction lending agency for the performance of the
I certify that I have read this application and state that the above information is correct. I agree to com with all
.work for which this permit is issued (Sec. 3097, Civ. C.). -
city and county ordinances and state laws relating to. building construction, and hereby authorize rep tativa
r
of this county to enter upon the above-mentioned property for inspection purposes.
property for
Lender's Name: '-
- -
Ste: j Z' O Signature (Applicant or Agent): -
' Lender's Address:
LQPERMIT
„ _,
Application Number 09-00000182
Permit RE -ROOF
Additional desc'-
Permit Fee 30.00
Plan Check Fee
.00
Issue Date . . . . .
Valuation
0
.
Expiration Date 8/2.9/09
Qty. Unit Charge Per
Extension
BASE FEE
30.00
Special Notes and _Comments
INSTALLATION OF NEW.TILE UNDERLAYMENT.
-
INCLUDES ADDRESSES:- 49-931, 49-941,
4.9-951
- ------------------------------------------
Other Fees BLDG STDS ADMIN (SB1473)
1.00
Fee summary. Charged Paid
Credited,
Due Y
--------
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 ..
-