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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
691 270 C-39 013/:401 »(
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.
( ) 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. 28SI 04-J3
(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.
,,Date: Applicant
N
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 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
co strUdon, and hereby authorize` re'presentativ s of this City to enter upon
the above-mentionedperty for inspection purposes.
/
Signature (Owner/A'gent),.,,%�� — Date
4C
BUILDING PERMIT PERMIT/t
04031-207
DATE VALUATION LOT .M" TRACT
(T IAMOC
•J B SITE
APN
ADDRESS ,"_3W A,(.L:1,NIJ)A,DWI
_
OWNER
CONTRACTOR / DESIGNER / ENGINEER
*YAC" a"/.-�P—M&I L
B i81•TDE R00, -WG & A.S80Cl. -ra, WC.
54.300AVYWIDADIAZ
31.435 VSA.LE PALM S
LAfMX_ TA (..A 92253
THOUSPNDPALMS CA 92276
(760)343-7555 C3- B 3533
USE OF PERMIT
ifi Rt3C11r1�;4d€tdfS1 x�S+CL.AS yA MIA.7'ERIALS ONLY.
VAWA1'jON ]A
OS .164ATF11 COST Or' CO.x`:SMt7G«' ON
PREMaT FIM S ITM'AVMRY
RERJOOF FEY 101.0,10.418.000
:tP,-a OPAL C;ON 1'"Ci?TTLMON' .FWD i7TAW CITZ4 "IC
$30.00
LrS.�3S P.R_8+ PAW FFES
$0.00
s D I O ' � I' �.:3 r Y� EF.S .M.&E
, Pow
D
MAR 112004
CITY OF LA QUINTA y�
RECEIPT ( j"7%/ ' �/
DAT, INALED_
INSPECTOR
I Ar—
V t�
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
I It
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:
r
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)
FEB -26-2004 11:36 POSTAL CONWCT10N
P. 02102
BUNnE ROOFING & ASSOCIATES, INC.
31435 Vin Las Palmas • Thousand Palms • CA s 92276
(760) 343-7555 o FAX (760) 343-7554
Sherry Tarzwell
54-300 Ave. Diaz
La Quints, CA 92253
Re: Estimate re -roof shingles with torch on
FOR THE SUM OF: $8.926.00
Note: includes removal and reinstallation of A/C unit
Wt
Mose to furnish and apply the followin_bor and materia!
Tear off existing roof and haul away. Inspect sheathing for dry rot, and replace any damaged wood on
a time and material basis at a rate of $40.00 per sheet (4 X 8 X V) replaced upon approval of owner or
his agent. Flat area (garage & section at rear approx.100 sq. ky. Install one layer of 28# base sheet
nailed to manufactuues specifications. Over base sheet, install one layer of modified bithuene torched
on as per mangy speeifications. Sloped area: Install one layer #15 pound felt nailed to secure.
Over felt install new 30 yea self-sealing 3 -Tab shingles to manufactures specifications. Install
individual units on all hips and ridges to compliment new roof. Clean and paint all roof flashings with
rust proof paint, replacing any found to be defective. Haul away all debris caused from above work and
leave area clean. This estimate includes no extras. If you have any questions regarding this bid please
feel free to gall. A five-year guarantee will be in effect upon payment in hill.
This estimate does not include any architectural fees if regained by planning committee.
TERMS: 100"/o UPON COMPLETION, UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE.
THIS ESTIMATE IS GOOD FOR 15 DAYS FROM DATE BELOW. THIS BID IS BASED ON CITY
r APPROVAL.
IT IS HEREBY AGREED BY BUNDE ROOFING d: ASSOCIATES, INC. AND THE OWNER THAT WE
THE CONTRACTOR SHALL NOT BE LIABLE FOR ANY OF THE FOLLOWING: DIRT, ROCK, OR ANY
DEBRIS THAT MAY FALL BETWEEN THE SHEATIBNIG BOARDS ONTO LIVING AREAS.
DAMAGES TO ANY CEILING MOUNTED FIXTURES, VENTS AND OR CONDUIT PIPES,
STRUCTURAL DEFECTS IN BUILDING_ IT WILL BE OWNER'S RESPONSIBII.TI"Y TO REMOVE AND
REPLACE ANY ROOF MOUNTED ANTENNAS AND/OR SOLAR PANELS.
IF THE SERVICES OF AN ATTORNEY MUST BE EMPLOYED TO ENFORCE COLLECTION, THE
OWNER AGREES TO PAY ANY ATTORNEY AND/OR COURT COSTS.
CONTRACTOR'S ARE REQUIRED BY LAW TO BE LICENSED AND REGULATED BY THE,
CONTRACTOR'S STATE LICENSE BOARD.
1020 N STREET
SACRAMENTO, CA 95814 LICENSE # 691270
Respectfully submitted by �/C '� �G�' t%!.� Date: Februanr 4. 2004
TOTAL P.02