0112-022 (RR)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
C39 C
Date Signature of Co�nt�ra`or
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.
*(/) I have and will maintain workers' compensation insurance, as required by
S c ion 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 Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
(J) I certify that in the performance of the work for which4his 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' comperpsation provisions of Section 3700 of the Labor
Code, I sh II forthwith complyi th�th�bse provisions.
Dat . 1 i f Appli { fL.r.r.MaJJjj:
flNarnmg: Failure to secuIe�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 he 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 wfKall City, and,State laws relating to the building
construction, and hereby aut�orize representatives of this. City to enter 'upon
the above-mentioned propp t, fpr inspection purposes.
Signature (Owner/Agent)""teff A! Date
r BUILDING PERMIT:.PERMT#
DATE .: _ a;�%iVALUATION 'LOT 011 TRACT
JOB SITE
APN
ADDRESS -180te,,YMATllUAF.Syt'.'Z
OWNER
CONTRACTOR / DESIGNER / EN (NEER
M�16.'�p IlAa.� MO
'6�'t1.Y' E ROC��:�WO
MAN 47��) A S.;.t't_ DA,. �F i.f;AR.tz..�3Z
P -F70 �.�'p,A,,''.Stt3Dv.raRE-PL
(760,072.2151 C 48717
USE OF PERMIT
RER00111,WIT" P110FACLASS MMIK1 f S'it3N bf-fttdCll..FA CLAEX A
REROOF Y's
ERMATM AT CM OF CC7M',C.£t'B7+1M'`11t" N
4,5000)i
MAIM, Fray, Hum"Ry
_
1AER00Y FRIE 1014€00.41 S-000 �If.Ga
nFc 0 5 2001
MY OF LA QUI6dTA
FINANCOZ
0
%M -TQM.. t:";(?AtS'1' UC—IMk1' ATfPLAbl!xCi
$0.00
.. dMWS kanpAYDEM
$0100
TOTAL
MOID
RECEIPT
DATEBY
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
Roof Deck
/�/d
/
Combustion Air
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 FirQwail
^
Exterior Lath
Drywall - Int. Lath
Final
BLOCKWALL AP ROVALS
Final
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
N aste 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
COMMENTS:
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)
tttata_-t�J
11100—
wa3fne
PROPOSAL & AGREEMENT
License #604598
(760) 772-2151 FAX (760) 772-2112
P.O. Box 1155 - Palm Desert, Ca. 92261
Date: 27 November 2001
Proposal Submitted 1b: Work To Be Performed At
Name: Mike Bailardo Job Site: 54-180 Juarez
Address: LaQuinta, Ca.
Address:
Phone:
Phone: FAX Approx. Das to Complete:
Reroofing House and Attached Garage
1. Tear off and haul away existing rock roofing.
2. Replace any dry rot plywood found at $30.00 per sheet.
3. Replace any facia board @ $5.00 per linear foot.
4. Install new 25 Yr. Dimensional Fiberglass Composition Shingle Roof (owner to select color).
Includes: %W_11
• 15 Ib. ASTM felt underlayment
• New 2" face drip edge metal 3itil��
• Raised profile hip & ridge trim
• Seal and paint all pipe flashings to match color of shingles
5. Grounds to be kept clean and all debris hauled away.
6. Price.includes Workers- Compensation and City Permit.
Respectfully submitted: WAYNE ROOFING, INC All material is guaranteed to be as specified, and the above work to be performed
in a workmanlike manner for the total sum of $ 4,500. 00 Dollars, plus any
additional wood replacement.
By Wayne A. Hitrick Payment Schedule: Upon Completion
Material Warranty: Mfgrs 25 Yr. on Shingles Labor Warranty: 5 Years
Section 7018.5 - Contractors License Law
Under the California Mechanics' Lien Law any con-
tractor, subcontractor, laborer, supplier or other person
who helps to improve your property, but is not paid for
his/her work or supplies, has a right to enforce a claim
against your property. This means that after a court
hearing your property could be sold by a court officer
and the proceeds of the sale used to satisfy the indebted-
ness. This can happen even if you have paid your con-
tractor in full but the subcontractor, laborers or suppliers
remain unpaid.
PROPOSAL
r4ouce to owner
Better Business Bureau
Business Arbitration Progrep
Any controversy or claim arising out of or relating to this
contract or the breach thereof shall be settled by
arbitration in accordance with the Uniform Rules for
Better. Business Bureau Arbitration, and the judgment
upon the award rendered by the arbitrator maybe entered
in any court having jurisdiction thereof.
Wayne Roofing Statement to Owner
Any alteration or deviation from'the above specifications
involving extra costs, will be executed only upon written
orders, and will become an extra charge over and above
the estimate. All agreements contingent upon strikes,
accidents or delays beyond our control. Owner to carry
Fire/Homeowners Insurance upon above work Worker's
Compensation and Public Liability Insurance on above work
to be taken out by Contractor.
The above prices, specifications and conditions are satisfactory and are hereby accepted You are authorized to do the work as specified. It is agreed that Payment
will be made as outlined above.
Signature: x
t--
Date:•2 `ci / Signature: