0403-202 (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
741152 C.39 10,141 Q;1
Signature of Contractor
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.
( r) 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 :YLA,TR 170141) Policy No. 2861-000094.2004
(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.
Rafl'e: Applicant
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 appiicaton 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)
Date
t BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
40.0
JOB SITE APN
ADDRESS tt GtJf3l'.Kjji%'�..rs�l
OWNER CONTRACTOR / DESIGNER / EN INEER
�'d3f'4id JD1i(I (33vA1:h l:j O.TECAIlve. 1D F114(3(K).
C01;rJT 1 LjN.1N'1<. 78 F,70 k11%rf3Wl:I'' l 3 1 .i°! �. ? f3 i
L.AQuIl-' p, CA, 921253 LAQLTtNTA
t f�c�j tp� n 0214 1921;
USE OF PERMIT
0RIJERP BUTi 11:i> 10
RL -RC QFV,71` H C=L&SS "A" MA'f2_21A1,5
VALUATION
12120100 LD,
�j (y',{.Q'p{ (J (_���J ,{���F&IDIWI711) COW QF C�`faS7S'1'.RT C1110N �.:X.�3(01013
1 *11,ft Y�.'i Y' ��iaJ' CY LJIM M�7.F R T.
RE.R.00F 175Z 101 -0(0418-000
;71=11
9015p�-r
C
r
AIM P1.,M011FICK $'.iv.c.0
I.iY y T'1:>tiaPq iTbCti ;to.00
RECEIPT I DATE i I BY I DATE FINALED I INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHAHl CAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
R tum Al
Steel
gombustion 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
P®®LS - SPAS
BL®CPWALL APPROVALS
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.
COMMENTS:
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)
PRH ROOFING, INC.
78-670 HIGHWAY 111 SUITE 185
LA QUINTA, CA 92253
(760)360-8099 .
LIC.# 741152
N ME/ADDRESS - I
SHARON KUNAKE
79-640 CORTEZ LN
LAQUINTA CA 92253
342=1708
PROPOSAL
' DATE
PROPOSAiL#
2/4/2004
468
FLE-12701:197
79-640 CORTEZ LN LAQUINTA CA.
DESCRIPTION TOTAL
REROOF W/ LT WT TILES
L REMOVE EXCMING ROOF TO SHEETING, INSTALL NEW PLYWOOD OVER
EXCISTING SPACE SHEETING.
2 °INSTALL ONE PLY #40 LBS FELT NAILED TO SHEETING, INSTALLNEW EDGE
METAL.
3. INSTALL NEW THE PAN. AND ALL OTHER METALS TO COMPLETE.
4. STACK TILE AND TRIM ON ROOF AND INSTALL AS PER SPECIFICATION
5. CLEAN UP JOB AND HAUL OFF DEBRIS.
6. PAINT ALL ROOF JACKS AND VENTS TO MATCH TILE; COLOR.
5 YEAR WARRANTY
Thank you for your business.
David Krastel, President
TOTAL
ACCEPTED. YOU.ARE AUTHORIZED TO DO THE WORK AS SPECIFIED. PAYMENT WILL BE MADE
AS OUTLINED ABOVE.
SIGNATURE
15,800.00
$15,800.00