0403-384 (RR)LICENSED CONTRACTOR DECLARATION
'Thereby 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 f �1� Exp. Date
C•39 MC i, C/713 112C
Date 0Slgnature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I.ani 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.
( ) 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:
Carver STATE.rta11D Policy No.
(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;,Ishall•forthwith comply withMose provisions.
'ate: `-Ajpplicant d1 ik• + -
Warning: Failure to secure Worker 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 (Owner/Agent) l/�, f 1._. Date
/
BUILDING PERMIT PERMIT#
o'MM-moi
DATE al J„145rK VALUATION $8,7450.00 LOT TRACT
JOB SITE ADDRESS t 9_020 �iV .N. is J�YrjArJJr)0 APN `
OWNER CONTRACTOR / DESIGNER / ENGINEER
49-020 AVENMDA,.i�.::u,WANDID 68760 SUNT10H DRIVE
I.P. QLm1 ' . CA 92253 C:'AMEDI RAL. CITY CA 92234.
(760)328-6616 CTLS 106
USE OF PERMIT
tI `+ice' CIMAL 17Ti �i)3k Ci
1.&RO0fP/FW1,'r UNCLASS .A° MATAPaA.LS 0N1,Y. 21701 Cna
VALUA21014 dF.1zR F
ENIMO COST OF i'ONY11RU+C:`l1014 8.1/60.00
l�,l�f�.z'�r�l• �� � r.)l da�o�4 � �o��a �3a,� j
/ -- -_
MAR 2 gG/ F
1004
CITY OF LA QUINyA _
FINANCE
DEPT.
SUB -TOTAL COITSTRITC7110-N AND PLAM CBE CK M0.00
,ESS PRE.-RAMYEBS [i.t3n
1
RECEIPT DATE-- �/ ��r BY' y•//"' DATE FINALE D INSPECTOR A/
Y•
INSPECTION RF
' OPERATION .
DATE
INSPECTOR
OPERATION_
DATE
INSPECTOR
BUILDING APPROVALS
"ME kANICAL 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
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:
W711, LUUJ 14;�U I U`, I i iL QUI II4L�, I 1 UI I
AL MILLER AND SONS ROOFING CO., INC.
"BETTER ROOFS FOR BETTER LIVING"
68-760 SUMMIT DRIVE, CATHEDRAL CITY, CA 92234 3C, oo .
PH. (760) 346-1214 FAX (760) 321-7097
LICENSE # 336547 '
PROPOSAL AND CONTRACT
Owner: Nils Nelson , My RA K( 1_ L. 0 Project: Nelson Res.
Address:P.O Box 152 Address: 49-020 Avenida Fernando
City: La Qunita, CA 92253 City: La Qunita, CA 92253
Phone:
WE PROPOSE TO FURNISH THE FOLLOWING MATERIALS AND PERFORM ALL LABOR TO ROOF THE ABOVE LOCATION.
extra charge of $32.00 ner sheet. Roofing contractor will then install a class "A" built up roof sgstenn
using the following materials. One (1) laver Glass Base mechanically fastened to roof decli:. Three (3)
layers glasply type IV (4) hot mopped with 251bs. asphalt between layers, 3/8" colored rock installed
in a flood coat of asphalt. Price includes new unpainted gravel stop, roof permits and taxes.
Roof Frice $$.760.00
Note: All mechanical, A/C unfits. A/C platforms. A/C Ducts must be disconnected, lifted and or
removed for new roof and reinstalled by others.
Terms Net Cash on Completion
ATTENTION
Section 7018 of the Contractors License Law provides that starting July 1, 1966, everyone licensed by the Contractor's License Board
shall give a copy of the following notice to the payor prior to receiving from the owner of the property or his agent any payment for work
which a contractor's license is required
NOTICE
"Under the mechanics' Lien Law , any subcontractor, laborer, supplier or other person who helps to improve your property but is not paid for �
there work or supplies, has a right to enforce a claim against your property. This means that, aticr a court hearing, your property could be sold
by a court officer for 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 subcontractor, laborer, or supplier remained unpaid."
Al Miller & Sons Roofing Co., Inc. Agrees to furnish its regular form GUARANTEE for 2 Years after completion of its said work. Said
guarantee to cover defects in material and workmanship only and not to extend to damage to roofmg caused by the elements, other unusual,
Acts of God and shall not cover any liability for damage to interiors fixtures, decorations, walls, contents of building or other pairs of structure'
not to damage of faulty construction. It is also understood and agreed that the above guarantee shall be made and remain only when and if
payrxicnt is made as agreed in this contract. Ai Miller & Sons is not responsible for TV antennas.
We are fully covered by Workmen's compensation and public liability insurance. Carriers' names and policy numbers are available on request.-
Any alterations or deviations from the above specifications involving extra,cost otimaterial or labor will only be executed upon written orders
for same, and will become an extra charge over sum mentioned in this proposal. All agreements must be made in writing. This offer is valid for,, -
one week from the date of estimate and is based on free access to building for direct loading from our truck. 11
Prices are based on current cost of material and labor, increases or decreases will be reflected at time of signing of contract. Al Miller & Sons
is not responsible for any damage to sidewalks, curbs or driveways. If there is any conflict between this proposal, and any other contraet;or,
specification relating to the above referenced project the terms of this proposal shall prevail.
Accepted,
Date: 11 /11 10 -�
AL MLEJt)& SONS ROOFING., INC.
By. john Lamons, Estimator
)atAf 09-09-03
TOTAL P. Gi _