BLDG (0210-288)51815 Avenida Madero
0210-288
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License -is in full force and effect.
License # Lic. Class Exp. Date
c MC
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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 & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the Jollowing declarations:
( ) I have and will maintain a certificate of consent to'self-insure for workers'
compensation, as provided for by Section 3700' of the Labor Code, for the
performance of the work for which this permit is 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 insurance carrier & policy no. are:
Carrier STATE F"I.T D Policy No. 161$416-.02
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply, with thoseiprovisions.
Date:-' f I 1 G} Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject'an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application. t
1. Each person upon whose behalf this application is made &each person r at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
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.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) --"Date
BUILDING PERMIT- PERMIT#
DATE VALUATION LOT " TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
TOM MEMM
ROOF TRE SPECIALTY
1, -815 f rMMA..I A A WRL0
74'A98O R'LUA A,Y:4: AY PR,
1.4't. Citrhmr' CA 92W3
BERNif..iS7A DUP93 QA. 922'.11
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(7f,0)200-,0811 MOO, 1420
USE OF PERMIT S
GENERA . BUR ZING
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VA."tAYATION, L111
157uWaD COST OF CONSTRUMON
PWF oow FEE 101.000-418-000 MUM
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$30,00
IMS PRI -11ATI F a`
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$303..0
CITY OF LA QU1NTA
1
FINANCE DEPT.
RECEIPT
DATE
BY ' -.r
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances — T- }
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
"J"'tw,1 iux i SPATE LICENSE # 810537
P.O. BOX 11257 PALM DESERT, CA 92255
PHONE 760-200-0811 FAX 760-200-0801
A proposal submitted to: TOM XMNICK
Mailing Address: 5.1815 AVE MADERO LA QUINTA, CA 92253
Job Address: SAME AS ABOVE
Phone: 760-341-2759
Description of Work to Be Performed:'
OBTAIN ALL REQUIRED CITY PERMITS.
REMOVE EXISTING TAR AND GRAVEL -ROOF AND DISPOSE.
NAIL ONE LAYER 40# TILE LINER.
INSTALL SHEET METAL AT ROOF TO WALL TRANSITIONS.
INSTALL LIGHT WIEGHT ROOF TILE TO
CLEAN JOB SITE TO OWNERS STANDARDS.
ACTURES SPECIFICATIONS.
PAINT ROOF JACKS TO MATCH TILE.
IF NOT ACCEPTED IN 30 DAYS THIS PROPOSAL IS NULL AND VOID
Notes: In Keeping With Industry standards: 1. This guarantee does not cover any damage to the interior or exterior
on which the roof is applied or damage to any contents therein. This
to any cause beyond our control, including, but not limited to: fire, lightning t windstorm, hailstee does not coverorm, to roof due
other equipment, foot traffic on roof, structural fault or settlement, cracking or other failure of tirenrro roof ant,
other
or foundation of the building on which the roof is applied. 2. Should it become necessary for the roofing
contractor to remove and/or reinstall any antennas, cooling or heating appliances or other equipment, whether or
not an additional charge is made for such work, the customer understands that neither Roof Tile Specialty nor the
installer assumes any responsibility for the performance of said equipment. 3. Roof Tile Specialty does not assume
any responsibility for corrections of existing code violations or for the repair of any existing defects unless
specified in estimate and proposal.
Total Cost: $6,250.00 Terms paid on completion unless otherwise specified in the contract. If not
acceptance in thirty days this proposal is invalid Extra $35.00 per sheet of plywood if needed.
Acceptance: You are hereby authorized to furnish all contents written in the contract to complete work mentioned
in the proposal contract for which I/we agree to pay the amount mentioned, in said proposal, and according to
terns thereof, . (Initial). If a leakage, caused by defects in workmanship, occurs within FIVE
from date of application, we will repair it free of charge. Years
Installation: it is understood that by the acceptance of this proposal you authorize Roof Tile Specialty -to make the
installation; to issue work order with specifications shown herein and to
pay our charge for such installation. You
agree to pay the amount the specified herein, which will cover the price of said materials and labor charge. This
estimate is based on a complete job and any surplus material remains property of Roof Tile Specialty. Verbal
understanding and agreements with representatives shall not be binding unless set forth herein. There shall be no
liabilities for delays in, or failure to complete, deliver or installation of all or any of the herein mentioned
merchandise, if due to fire, strikes, war, government regulations, or any cause beyond our contract. Any changes
made by you in specifications herein, necessitating additional materials or labor shall not be included or covered
by this proposal, but shall be provided for under separate and additional order from you. (1
Arbitration of disputes: Any controversy or claim arising out of relating to this contract, or the breach thereof,
shall be settled by arbitrator in accordance with the applicable Construction Industry Arbitrator Rules of the
American Arbitration Association which are in effect at the time the demand for arbitration is filed. A judgement
upon the award rendered by the arbitrator(s) may be entered in court having jurisdiction thereof. Any arbitration
award shall be subject to correction and/or vacation for the reasons stated in the code of civil Procedum. ThP
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