BLDG (0305-180)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 DATE
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
JOB SITE
?fSl 51 r'39 ,� 0 12( ADDRESS
a,,vrSignature of Contractor, �'��'�-� -. OWNER
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 following 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.
( t) I have and will maintain workers' compensation insurance, as required by
S' tion 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 FUND Policy No. 28$-02-0002001
(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 t ose provisions
,'`Date` - Applicant—. r—�o _.
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.
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 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 (OwnerAgen:—Cr�
Date'—
..
BUILDING- PERMIT
VALUATION LOT
a +&71760.00
52.935 AVEWDA NAVARRO
LA QWNTA
USE OF PERMIT
PERMIT #
�1 TRACT
APN
CONTRACTOR/DESIGNER/ENGINEER
AT � `.NE 0017 COMPANY
PS), BOX' 167
CA 92253 YUCCA V kUXY CA 02284
(760)365-3300 MLO 3153
R.&ROOF11OTH 3 PLY BUILT-UP ROOD'SYSTEDA, C'LAS2 "A"
MATERIALS
VALUATION
21760.00 11.01
4'
)FKRZ UT T)'E E S'C'ARY
RE -ROOF FEE 101-000-418-000 $30,00
V
E'l
I
CITY t)"
D-'.Y`Q'iAT,, C0t;JS'M.UCT1?01T.*W .PL" C'l:i7.= $130.00
7.Y.°S PR:E P,P,W FHE,:1 $0.00
I$�'J't��.
RECEIPT DATE BY DAJ&RblALED.
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 15 05
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 I
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 Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: ' .s
0
Purc S C O �� C HOME REHABILITATION
PROGRAM
5555 Arlington Avenue -
The following number must appear on all related P. O. Box 4637
correspondence and invoices: CDBG Riverside, CA 92514
Toll Free #: (800) 909-0079
Reference Number: 6267
RDA Fax: (909) 352-4852
Contractor:
Alpine Roof Company
P.O. Box 167
Yucca Valley, CA 92286
(760) 365-3100
Homeowner:
Billy Scott
52935 Avenida Navarro
La Quinta, CA 92253
(760) 771-9419
ITEMIZED DESCRIPTION OF WORKI TIME FOR COMPLETION OF
WORK: DAYS
Per proposal dated 7/30/02: Remove one roof and leave insulation intact then install 3 -ply built-up roof. One
28 lbs base, one 11 lbs ply and 72 lbs capsheet. Asphalt applied between all layers. Five-year guarantee on
labor and workmanship.
A//� 4o- 17 ( N)
2
Supervisor Date veld Spe. list Date
5n+.s'Y
531
P.O. DATE NUMBER OF
".' JTIF et,�
a �FOROF+FI'CE
WINE
ti i#•c'4ke^�;aa,.kluda3a:
WORIC.SHALL COMMENCE
NO LATER THAN 45 DAYS
r'.ii
USEONLY�
.r'3.+k ry.•7ASFiH.iviksr i
PROJECTED
COMPLETION-
w
,
it ,
p 0: AMOUNT
=` TOTAL COST OF
PROJECT INCLUDING
-P.O.(s)•ISSUED
FROM DATE OF P O
OF WORK: ..
THIS P O -.
2/20/2003
1 of 1
4/6/2003
5/21/2003
$2,760.00
$2,760.00
CONTRACTOR: PLEASE SUBMIT INVOICE WITHIN 10 DAYS OF COMPLETION OF WORK. PAYMENT WILL BE
REMITTED WITHIN 30 DAYS OF INSPECTION BY SENIOR HOME REPAIR STAFF. THANK YOU.
(:users\hsgdata\hipshr.mdb\rpt PurchaseOrderHR
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
r,
Received From: 2IT J O
Date:
Address:
Account No XY e
Service Address
0 Metdr(s)
0 Service(s)
A0
E47 rit-) I --F t
0 Backflow(s)
0 House Laterals)
0 Detector Check(,)
0 Meter Surcharge
Sanitation Capacity Charge
0 W.S.B.F.C.
T,
0 Temporary Construction Meter
0 Turn on Charge
0 Uncollected Account - Name
0 Inspection Fee - Tract -
Fee -
. ❑
.0 Plan Check Fees Water Sewer -
Tract -
0 Bond Payment 7 A.D. - Bond
Assmt.
0 Customer Deposit
0 Other
Remarks:
Tract—
G.A. Code
TOTAL $
OCOPY to:
Cash
Check Water Service
Money
Order
Cashier Ca
...... — CVWD-438 (11189)