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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
6250t'l8 C39 0813112(
Date -/ ' Signature of Contra
OWNER -BUILDER DECLAR�A' ION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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
V 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'
cdmpensation, 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 0TA"!'9 FVWD Policy No. $001100020
(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 those provisions. ; •r-`
DaterApplicant
ruing: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penaltw's' 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. ,� y
Signature (Owner/Agen4p^"•"��
USFIECTM 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
—�
0. 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
-- -- -
fr^fl2!
Canal _
__
POOLS SpIf%5
KU'''XWALLL� APPROVALS
_
�5ei_ 1;WC_kS_ — -�
steel
Electric Bond
----
Footings
Main Drain
_ _ _
Band Beam _ _
Approval to Cover
Equipment Location
_
Underground Electric
Underground Plbg. Test
Wasvg.Lines �i
Gas Piping
—_
Gas Test
Electric Final
Heater Final
VUate%,�ipfng
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pens
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection ry
Encapsulation
Gas Piping
Gas Test _
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
C -L C C`P=AL 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)
CUSTOM ROOFING COMPANY
38-980 RANCHO LOS COYOTES
INDIO CA 92203
PHONE: (760) 345-3751
DATE: September 28, 2001
TO: BEN OLSON
79-661 CORTEZ LANE
LA QUINTA CA 92253
30B -ADDRESS: 79-66i CORTEZ LANE
CA LIC. NO. 625038 PROPOSAL NO.1
SHEET NO. 1
PROPOSAL AND CONTRACT
PHONE:
LA QUINTA CA
SPECIFICATION AND UNDERSTANDING: Tear off existing roof. Reshed roof area. Install 2 layers 40 lb file liner to
roof deck. Install new U S. Tile (teas cotta color) per manufachures recommendations, : Custom Roof ng Company is responsible for
clean up and removal of roofing debris from property.
SPECIAL INSTRUCTIONS AND NOTES: (1). A deposit may be required to cover the cost ofmaterial. Draws on
balance -due may be required. (2). Any sheeting needed will be an extra charge of $30.00 per sheet above contract price. (3). Any air
conditioners, water coolers, duct work, electrical, etc., that needs unhooked, moved, pu removed from the roof will be the owner's
responsibility above contract price. (4). Amy drains.that need replaced or installed will; be an extra charge above oo®trad price.
TOTAL COSI': $14,200.00 (FOURTEEN THOUSAND TWO HUNDRED DOLLARS AND NO CENTS.)
TERMS: TO BE PAID IN FULL ON COMPLETION UNLESS, OTHERWISE<SPECIFIED IN THE CONTRACT.
FTYE`(5)YEAR guarantee against leaks on Custom Roofing Company's work only.
NDTF.: BECAiISir OF ?ilE R,9PID RISE IN THE DOST OF MATERIAL.THIS PROPOSAL iYILL BE NULL AND V0113
AFTER !S DAYS JOB ?L') BE STARTED INA T7MELYMANNER ACCORDING 1t0,SCHEpULE AND I1THER CQNDl7TONS
IN iCEEI'dNG WITH INDUSTRY 3TANDARDSt (1). This.guarantee does not cover any damage to the interior or
exterior on which the'roof'is applied or damage to any ear►tems therein. This guaranteedoes not cover any damage to roof due to any
cause beyond our control•including, but not limited to, fire, lightning, windstorm, hailstorm, rainstorm, installation of antennas, or
other equipment, foot traffic .on: root strut tuml fault or settlement, cracking or other failure .of. roof deck, walls or foundations of the
building on.whic h the roof is applied (2). Should it became necessary for.the roofing cxmtrmtorr to remove and/or reinstall any
antennas, cooling or heating appliances; or other, equipment, whether or not any additional charge is made•for such work, customer
undeastands'that neither Custo '-R,00fing Company; nor installer assumes any responsibility; far. the performance of said equipment.
(3} Custom Roofing Company does not assume any responsibility for existing code violations or for the installation of any existing
detects unless specified in the estimate and proposal.
ACCEPTANCE: You are hereby authorized to furnish all contents written in this contract to complete the work mentled
in the proposal and contract for which Uwe agree to pay the, amount mentioned in said proposal and according to the terms thenRZ
IN KEEPING WITH INDUSTRY STANDARDS It is understood -that. by the aomptance of this proposal you authorize
Custom Roofing Companyto•make the installation, to issue work arder with specifications shown herein and to pay our charge for
such installation. You agree to pay Custom Roofing Company the amount specified herein, which will cover the price of said
materials and labor charges. This estimate is based on •complete. job and any surplus material remains the property of Custom Roofing
Company. 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 ofthe1erein mentioned.merchandise, if due to fire,
strikes, war, governmental regulations, or any cause beyond our control.: Any changes made by you in specifications herein, .
necessitating additional.taaterials or labor shall not be included or covered: Ter by,.this proposal, .but shall be provided for under a
separate and additional: order from year. =
OWNER'S SIGNATURE: DATE:
CONTRACTORS SIGNATURE: DATE: .
(PLEASE SEE OTHER SIDE)..