0312-105 (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. /11
License # Lic. Class. Exp. Date
460707 C39 8/31104
%(/- C'
'Date Signature of Contra f r
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
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 STATE FUND Policy No. 159+/1523-01
J (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 agreetthat-rifl should become
1 subject to the workers' compensationipro visions of Section 3700 of the Labor
t Code Ishall forthwith comply with tho
te se.pr. visions:
DaApplicant ( ��
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
1 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
bpermit, or cessation of work for 180 days will subject permit to cancellation.
I
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 representative s of this City to enter upon
the above-mentioned property for inspectip urposes.
�
/Signature (Owner/Agent -,I l I/
Date/2'�����'�
PERMIT# •'
;.BUILDING PERMIT
DATE , , : -VALUATION LOT 0312-105 TRACT
JOB SITE APN
ADDRESS
W11-25 AMMAVEL CO
OWNER CONTRACTOR/DESIGNER/EN (NEER
52.525 AV.EN3bAVa- A3C0 68-314MLIFYIM
LA QT.lItTA CA 9253 C:AMEDRAL C.`.r1'Y CA fa234
(780,)324-5482 CBVA 5230
USE OF PERMIT
R&ROOPWITH CLASS W MATERtAU;
VALUATION
S%00.001.13
PE!?mn'::+.1t.`E WJ'"Pt!.e�l ARY
REROO F + R 101-000-418-000 $30.00
'I®
DEC 101003
CITY OF LA QUINYA
FINANCE DEPT.
Sins-TurAL CONTIMUMO
J1
D'PT. W (-I'M-=
LFZ3 PRE-VAID FUS
TC TAT QFC:k°diMTno:$?'.IsDYlENOW
RECEIPT DATE f BY r DATE FINALED INSPECTOR
51000.00
$30.00
$0,00
$30.00
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
POOLS - SPAS
BLOCKWALL 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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
/ Y
C (�
b
9
4
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
MMainS
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Nov -17-03 12:34pm From -DESERT BUSINESS MACHINES 760-346-1944 T-091 P.02/02 F-055
THE R F R O'O F I N G SPECIALISTS' t N C.
"Since 1980^
ROOFIM®
Cur orate ORice: Desert Office:
2626 Newport Blvd. 68-314 Kieley Road
Costa Mesh CA 92627 Cathedral City CA 92234
949-548-1645 / Fax: 949,548-2617 Liccnsc 0460707 760-324.5482 / Fax: 70.328.4612
PETROIVEL.LA ROOFING nercinaftcr called 'Cunw=voP' and/or-Scllcr- xtgtes w provide the zbllowing llxsea labor rr7ScS'W% and cAins[nactiun:
NAME / OWNER; jRNNt.BF.R GROSJEAN
REROOF PROJECT ADDRESS: 52-525,A.VENLPA VF -I. -ASCO
CITY, STATE A ZIP CODE:
BIi LING ADDRESS:
CI'T'Y, STATE & ZIP CODE:
L.A QUINTA. CA 92353
ADDITIONAL PHONE NUMBER: 760/773.9862
wol l zl g
PHONE NO-: 76U/346.1124
EA C 1Vi MiSEiR:
Pmronolla Aaolius will furnish all labor and materials for ro-roofing as per proposal date~! duly 29, 2003.
Option N2
Reroof with 25 Year Composition Shingle: by Owens Corning
GUA►AAN i'EE
Petraavlla Roofing will guarantee root(a) from !caking due to workmanship or materials for TEN (10) years.
ROOFING CONTRACT PRICES
Pilen Area/35 Year material warranty
2S Year Class "A- Cumposkloa ShinRkft _-
COST TO (NSTALL 2S YEAR DIMENSIONAL SHINGLE ............................................ o
,{{AI�I fascias bbo/a�(r�d7s� *need to be replaced_ Primcd and painted at 996-50 per foot.
_ _ ----
� i4�i�FAR•/.A1�--•]?aa:-,7•�•1�7�.2-.i. ]R •Zi 327tr•• •. .---tl.!•1��7•11• �R•�7.1.. �1�-. •saal t.l apt r.l l f e
SPECYAL INSTRUCTIONS: CONTRACT TERMS:
SCIr3[iDULF OF .EXTRAS 10% upon Award of Contract:
1. Remove and replace any damaged or dawriorated plywood at $2.00 per sq. ft.
2. Any electrical or plumbing work will be charged $67. 50 per man per hour-'�
and materials plus 100/..
X500/ ..Ilnnn.�COmpletiOD
t,
EK)TARTINCAND COmPLfiTINCPRO)EC7r'. Won. ]hall t:bMmence within Gen (10) any3 bom the dale of stile unlos specified otnerw.se
�,y,(�„� . act be yYOWGntially complated to approx.maldy ten (10) working day, v.ith oddatonol tune w tie xa aetallea in P.yagrapL 9 of the
Tarin$. COttUt .uns 2nd -Notice w Owner' ..n the bail; hCimr. Subszarlttal Conemencemcut of work :hall be dctiocd o3 the inataJeahon of airy materials and/or labor
C'onzramrs fa.Iure to s..bsunhally .dmmanee wor4, wiMOM& la rva cxausa. w.than Monty (20) dgyz from enc dax sp=4CA:4. above is a violation of rhe Conumcrots
Wa.nic 1 aW. ,
NOTICETOBUYeR (1) Do not sign tn.s e.nent befbre yu.. regia .c (z) You ata OnTIUad to a .:Omplelely filled in .,opy nrthia aw"utent (3) Owner 1
n..mor.acd R.:spodsible pally uknu.viedCcs .bot ne / sne nm rind acid ieee.t•ed a legible c,,Py ..r RlE tel] Aere4LsLj l SJ4' �r4 by CunW"cwr, IpplAA&MIS mJI Tvrin:,
Coneiuunt and-Wot.ec Co O•vn -f" 0.4 tier tcvcnc ytde. ocram any -um was dune and the he / ium ►ra: te4u anu r—ivca a lcgiola Copy of:very40CWnrnl that Owner/
Autnorih-d Re-.pon3.b1, party Itus 3+uac4 dunnrr. the nc7godidons (4) YOU, THE BUYER, ivinY C^NCeL TaiTS 'rRANSACTION'AT ANY TWE YKJOK TV
MIUNI(jH'r OF THE THIRD BUSINESS DAY AFTEK I'Hc DATE OF THAN TRANSACTION (3Y NCrr0-Y1Nu THE SELLER. rN WRITINC , A'r'I'H1- AUUVF:
ADDRENS IN THF EVENT YOU THE BUYER FA.L5 TO EXERCiSE TH1y RIGHT AND SUBSfQUtiNtLY s>TTHARPTS TO CANCEL'PHIS CONT&AL-T
AFTER THE EFCCTIVE DATE 1E' RECISION. THE CONTRACTOR SHALL BE ENTITLF0 TO RECOVER saJ_L CO:O'S saND 1-0aT PROFITS ASSOCIATC-D
W1T1.1 'PHIS CONTRACT. (51 YOU. AS OWNER OR TENANT, r(^VE THE WGriT TO REQUIRE- THE CONi-KR4�-7OR TO HAVE A PERFOMANCU AND
PAYMENT BOND UR FUNDING CONTROL
Owner /
D.re
r'1
PARTY
.me.
CONTRACTOR (SELLER)
CONTRACT PfUCE
[:FORGE PEMNL.L.A
Petroaclim Roo it AvchU"xxd Kcprtxoartive: Pnur Nittne
Pcwnello R00609 Autburixcd Kcprocmndve: Signature <
t
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