RR (9511-091)a LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing wi
Section 7000) of Division 3 of the Business and Professionals Code, and n
License is in full force and effect. j 1014 (;_3,}
License # Lia Class Exp. Date
Date //-_ t��s SignatureofContractor�.. ��.,�,,�
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for ti
following reason:
( ) I, as owner of the property, or my employees with wages as their sc
compensation, will do the work, and the structure is not intended or offered f
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with IicenrA
contractors to construct the project (Sec. 7044, Business & Professionals Codi
( ) 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 following declarations:
( ) I have and will maintain a certificate of consent to self -insure for worker
compensation, as provided for by Section 3700 of the Labor Code, for if
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required I
Section 3700 of the Labor Code, for the performance of the work for which th
permit is issued. My workers' compensation insurance carrier & policy no. ar
Carrier 4 i.> rF k €ii%'Q Policy No. 16449+ i- W
(This section need not be completed if the permit valuation is for $100.00 or les-
( ) I certify that in the performance of the work for which this permit is issue
I shall not employ any person in any manner so as to become subject to if
workers' compensation laws of California, and agree that if I should becon
subject to the workers' compensation provisions of Section 3700 of the Lab
Code, I shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and shI
subject an employer to criminal penalties and civil fines up to $100,000,
addition to the cost of compensation, damages as provided for in Section 37(
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safe
for a permit subject to the conditions and restrictions set forth on his applicatio
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 agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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
correct. I agree to comply with all City, and State laws relating to the buildir
construction, and hereby authorize representatives of this City to enter upon tF
above-mentioned propertyfor inspection purposes:
8lgnature (Owner/Agent) Date 11-30-9
FEE DESCRIPTION I FEES
CUM RACT AWiO T Z7LV.00 LS
COST OF CONISTRIJ IMMONi
ROOF F%c; 101-01DO-418-000 530.00
2,700.00
ALC.., _
BUILDING PERMIT
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FEE DESCRIPTION I FEES
CUM RACT AWiO T Z7LV.00 LS
COST OF CONISTRIJ IMMONi
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2,700.00
Scr (H -TOTAL CONS'tRCfCfiION AND PL�r�4Nft ti".fiECK�
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RECEIPT
I DATE
BY
DATE RNALED
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 / 20 9
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 /Vz
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
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
CLASSIC ROOFING
10197 NANCY AVE
CHERRY VALLEY, CA.
SUZANNE 92223 LONNIE
(909)845-2425 (619)365-4720
DATE:10/21/1995 LIC# 521054
NAME:ROSENTHALL & ASSOC. JOB NAME:B J
ADDRESS:72-261 HWY 111, SUITE B7 ADDRESS:51450 AVENIDA NAVARRO
CITY:PALM DESERT ST:CA CITY:LA QUINTA ST:CA
ZIP:92260 PHONE:(619)564-2343 ZIP:92260 PHONE:(619) -
tear off old roof down to sheeting. replace bad plywood at a time and
material rate of $30 per sheet, (at owners consent). reroof flat roof
using as follows: nail one layer of #28.basesheet, and torch apply
APP rubber roofing membrane. roof house using one layer of #15 felt
underlayment, install new metal edge, and install 25 year elk
prestique II fiberglass shingles with windguard. install redi-ridge
on ridges. mastic and paint roof flashings.
5 year labor warranty
NOTE: OWNER WILL PAY TO HAVE A/C UNIT REMOVED AND REINSTALLED AT
APPROPRIATE TIME.
NOTE:STATE FUND WORKERS COMP #1044971-94
THANK YOU!
..:>::>:>:;: .WEPROPOSE HERE$Y . TO
FURNISH MATERIAL
AND LABOR COMPLETE IN ACCORDANCE -"
WITH ABOVE SPECIFICATIONS, FOR THE SUM OF: 2700.00
DEPOSIT OF: 0.00 NEEDED TO START YOUR PROJECT.BALANCE OF 2700.00
TO'BE PAID UPON COMPLETION. THANK YOU!
SIGNATURE OF ACCEPTANCE:
DATE:
AUTHORIZED SIGNATURE:
SALES: LONNIE BUSKIRK
DATE:10/21/1995 10.1
in compliance with license law, sec 7018, (b & P code. div. 3,
chap. 9) this is to inform you that under the mechanics- lien
law (california code of civil procedure, section 11.81 et seq.)
any contractor, sub -contractor, laborer, supplier or other
person who helps to improve your property but is not paid for
his work or supplies, has a right to enforce a claim against
your property. this means that after a court hearing, your pro-
erty could be sold by a court officer and the proceeds of the
sale used to satisfy the, indebtedness. this can happen even if
you have paid your own contractor in full, if the sub -contractor
laborer, or supplier, remains unpaid.