05-3297 (RR)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253,
Application Number:
05-00003297
Property Address:
49499—EISENH0WER DR
APN.
658-190-011-30 -28545
Application description:
RE -ROOF
Property Zoning:
TOURIST COMMERCIAL
Application valuation:
750
Applicant:
T`ty/ 4
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Architect or Engineer:
aD lA
AUG 01 2005.
OF LA QUINTA
{�oorv�s 350 -- 55`T
wner:
A QUINTA RESORTS
9-499 EISENHOWER DRIVE
A"QUI"NTA, CA 92253
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Z!A O , RAYMOND
35688 CATHEDRAL CANYON DR #204
CATHEDRAL CITY, CA 92234
(760)333-3556
Lic. No.: 570657
Date: 8/O1/05
-------------------------------------------------------------------------------------------------
' NSED CONTRACTOR'S DECLARATION
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of per' ry that I a licens u der provisions of Chapter 9 (commencing with -
I hereby affirm under penalty of perjury one of the following declarations:
Section 7000) of Division of the usiness an P fe ion s 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
las C33 " C39 icense No.: 570657 -
_
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
Qate•
tractor:
issued.
have -and will maintain workers' compensationinsurance, 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 carrie'r 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 22613
following reason (Sec. 7031 .5, Business and Professions Code: Any city or county that requires a permit to
f the wor
_ I certify that, in.theghould
or 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 mbe amu
ect to the workers' comp 'sation 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, iu sect
o the workers' compe tionprovisions of -Section
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
3700 of th abl o comply with those visions.
that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7631.5 by
any applicant fora permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
Date: Applicant:
(_ 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
WARN( AILURE 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,
SUBJEC 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 IS100,000). 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 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 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
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:
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 160 days from date of issuatheabo
or cessation of work for 180 days will subject
permit to cancellation.
I certif that I have read this application and staor do is correct. I agree to comply with all
city an co ty ordinances and state laws relatiu ion, nd hereby authorize representativ
of t oun y to enter upon the above-mentiono urposes.
Dar ignatur
LQPERMIT
Application Number
05-00003297
Permit
RE -ROOF
Additional desc .
Permit Fee
30.00'.Plan
Check
Fee
.00
Issue•Date.. .
.
Valuation
0
Expiration Date
1/28/06
Qty Unit Charge
Per
Extension
BASE
FEE
30.00
Special Notes and
Comments
RE -ROOF WITH POLY
URETHANE FOAM,
ROOMS
350-357.
.Fee summary
Charged
Paid Credited
Due
" Permit Fee Total
-30.00
.00
.00
30.00
Plan Check Total
._00
.00
.00
.00
Grand Total
30.00
.00
.00
30.00