0203-011 (MISC)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.
License # Lic. Class Exp. Date
Date 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).
O I am exempt under SectionB&P.C'�for this s reason
Datec.&`Z_ Signature of Owner--�..°i�..�� r�
WORKER'S COMPENSATION DECLARATION
�,,,
I hereby affirm under penalty of perjury one of thb3following 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 Policy No.
(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 i
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: 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. y.
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.
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Signature (Owner/Agent).-i~• Date L
UIL_ DING PERMIT ' ~ PERMIT# ,
_
DATE vALbATI0N LOT 0.20 - 11 TRACT
JOB SITE
APN
ADDRESS ,pp�tt•s�.� •��,��{►; p� qq, t`yy� �yy AA
.5A,"`.725 A.PIA'w,FV ::Pf 7t A.,i".�JI�t.4: A
•••
OWNER
CONTRACTOR/DESIGNER/EN (NEER
'RIC'UVi D KOIA LOW
•" 73` ! DER
57.825 AVINWAVXIA
USE OF PERMIT
RX-IZOCIF PATIO WITH R"sMV }it $LL L3 MND '1'Ab2}ZED kOt'sf IND
VALUATION 1z3�ft.lyll !.:
Et"IMMIX:D COST Ora CONS TRUM014,
1,390.00
RFROOF F—Me 101-000-418-00 SAM
'MAR 04 2002 `
WYOFLAQUIWA
��';t B- AX. t::`C9. .�UCTI(3i�1".tssND P3�A;X C ` 4,3C
,e ESN PP.F-T*ATD F.'�-'M
$0.00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR Y 9
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
!
I
Underground Ducts
Forms & Footings
)
Ducts
Slab Grade
3
;
Return Air
Steel
'i
Combustion Air
Roof Deck
!
Exhaust Fans
0. K. to Wrap
+
F.A.U.
Framing
y
Compressor
Insulation
i
,
Vents
Fireplace P.L.
{ ;
Grills
Fireplace T.O.
l I
Fans & Controls
Party Wall Insulation
[
Condensate Lines
Party Wall Firewall
i
+
Exterior Lath
{
Drywall - Int. Lath
i
'[
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS }
►
steel
Set Backs
i
Electric Bond
Footings
Main Drain
Bond Beam
; ''
Approval to Cover
I
Equipment Location
Underground Electric
Underground Plbg. Test
Final
t
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
l
Heater Final ,
' ltvater Piping
I
Plumbing Final
Plumbing Top Out
;
Equipment Enclosure
hower Pans
!
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation'
Gas Piping
I
i
Gas Test
r
Appliances
r
i
Final
'
COMMENTS:
I
;.2
Final
Utility Notice (Gas)
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j
ELECTRICAL APPROVALS'
Temp. Power Pole
;
I
Underground Conduit
1
Rough Wiring
Low Voltage Wiring
)
'
Fixtures
Main Service
Sub Panels
f
Exterior Receptacles
;
G.F.I.
Smoke Detectors
;
t
Temp. Use of Power
Final
Utility Notice (Perm)
[
ESTABLISHED 1923
State License No. 715997
DATE: 2/26/2002
JOB ADDRESS: SANTE
CITY:
L.A. STAR -ROOF CO.
79-130 CLIFF ST. BERMUDA DUNES, CA. 92201
760-345-3525 FAX: 760-345-4439
CROSS STREET: AVE. 52 & EISENHOWER
OWNER: RICK KOTHLOW
ADDRESS: 51-825 AVENIDA VILLA
CITY: - LA QUINTA, CA. 92253
FAMILY OWNED SINCE 1932
Los Angeles: 323-292-8145
TOTAL PRICE OF JOB: $1,390.00
DEPOSIT: $ 390.00
COMPLETICN OF JOB: $1,000,00
COLOR:
WHITE
HOME PHONE:
760-564-5477
BUS. PHONE
FAX PHONE:
CULL PHONL.:
760-774-3263
EST #:2006. D2
CONT.#
IVL AGREE TO FURIYISII LABOR AND MATERIAL ON THE JOB ADDRESS LISTED ABOVE AND PERFORM THE SAME ON THE ITEMS LISTED BELOW:
ON THE ENTIRE FLAT ROOF OF TETE PATIO IN THE REAR
L Tear off all roofing down to the sheeting and hatil away. Note: Tear off to be done by customer..
2. Install 1"x 2" White metal edging to all edges.
3. Install one laver of 25# GS base felt nailed on,'
4. Install 1 layer(s)of 11# GS interply felt mopped on With high melt point hot asphalt at the rate.of 30 t -) J35 pounds per 100 sq. ft.
5. Install 1 layers) of 75# GS Capsheet mopped on with high melt point hot asphalt it the rate of 30 to -35 pounds per 100 sq. ft.
6. Install a bead of Henry's roof cement along all perimeter edges with edging prior to installation of the capsheet. NOTE: THIS
PREVENTS WATER RUNNING UNDER THE ROOF FROM THE OUTSIDE EDGE AND HELPS PREVENT WIND DAMAGE.
7. Remove any old seals. Clean and prime as needed. Seal edges with a layer of #204 roof cement, a layer of 4" fabric cloth, and an
additional layer of roof cement.
8. Remove all ralce tile at the rear off the house and reset in place. Punch out or drill tile as needed to secure them properly. Also install
roof cement to help prevent any future wind damage. If my additional tiles need to be adjusted or replaced it will cost $6.00 each or
$65.00 per man hour, depending, on what has to be done.
9. Send_ a supervisor out during or after completion of the job to confirm all work has been done to contract specifications and the
premises have been left clean.
We will obtain Duly necessary permit fee's if desired or required for $85.00 plus the cost of the pennit which is usually around 1% of the contract price.
OPTION (A) FOR A 20 YEAR LIFE EXPEDIENCY ROOF INSTEAD OF A 15 YEAR LIFE. .
1. Install one additional 11# interply felt at the rate of 30 to 35 pounds per 100 sq. ft. to provide extra strength, additional waterproofing
and an extended life to the roof. The roof will then consist of 4 lavers of roll roofing and 3 lavers of hot asphalt
THE PRICE .FOR OPTION "A" IS $125.00.
NOTE: ONLY THE BASIC SPECIFICATIONS WILL BE DONE UNLESS ANY OPTIONS ARE INITIALED.
NOTE: WE USE THE BEST, MATERIALS AVAILABLE AND INSTALL THEM AT. OR ABOVE MANUFACTURERS
SPECIFICATIONS. WE US GS ROOFING MATERIALS; TRUMBELL ASPHALT MANUFACTURED BY OWENS CORNING,
AND HENRY'S SEALANT PRODUCTS. MOST OF THE TIME THESE BRANDS ARE MORE EXPENSIVE THEN THE
COMPETITION. WE FEEL THEY DO A BETTER JOB. THE MINIMUM AMOUNT OF HOT ASPHALT REQUIRED BY
MANUFACTURERS IS 25#'S PER 100 SQ. FT. AS SPECIFIED ABOVE, WE ARE INSTALLING IT AT 30 TO 35#'S PER 100 SQ.
FT. WE ARE INSTALLING 20-40% MORE THAN REQUIRED BY THE MANUFACTURERS.,. DUALITY IS IMPORTANT.
We agree to maintain your new roof free of charge for _ 5 vears rot- causca glue to labor aril materials on the areas & items we worked on only.
L
OWNER/BUILDER INFORMATION
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified.
For your protection you should be aware that as "Owner/ Builder'' you are the responsible party of 'record on such a
permit. Building permits are not required to be signed by property owners unless they are perso_ially performing their
own work. If your work is being performed by someone other than. yourself, you may protect ?ourself from possible
liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the.State of California and to have a business license
from the City or County. They are also required by lawto put their license number on all permits for which they
apply.
If you plan to do your own work, with the exception of various trades that you plan to subcontiact, you should be
aware of the following information for your benefit and protection:
If you employ or otherwise.engage any persons other than your immediate family, and the work (including materials.
and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or
subcontractors, then you may be an employer.
If you are an employer, you must register with the State and Federal Government as an employer and you are subject
to several obligations including State and Federal income tax withholding, federal social security'taxes, worker's
compensation insurance, disability insurance costs and unemployment compensation contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with
respect to'worker's compensation insurance.
For more specific information about your obligations under.Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under State
Law, contact the Department of Benefit Payments and the Division of Industrial Accidents.
If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their
work personally or through their own employees, without a licensed contractor or subcontractor , only under limited
conditions.
A frequent practice of unlicensed persons professing to' be contractors is,to secure an "Owner/ Builder" building
permit, erroneously implying that the property owner is providing his or her own labor and: material personally.
Building permits are not required to be signed by property owners unless they are performing 'their own work
personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your
community or at 1020 N. Street, Sacramento, California 95814.
Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of
these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico'
La Quinta CA 92253
777-7012
FAK 01'%!��/ x
FAX: (7677 O1
OWNER' SIGNATURE/DA
PROPERTY ADDRESS
0a03- o Ll
PERMIT NUMBER(s)