0201-110 (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
Profegri6nalS Code, and my License is in full force and effect.
Lice se # Lic. Class Exp. Date
7 � C.39 - 030/02
;Date i" Signature of Contracto
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
t
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and wile 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:
CartierPolicy No.
f 00400108f,101
(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 tole workers' compensation provisions of Section 3700 of the Labor
Code Xshal forthwith comply with, thos provisions.
Applicant a_ �yz,!'9 y.•" .'`�1
.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
construction; and hereby authorize representatives of this City to enter upon
the above mentioned property for inspection purposes.
€S . igateure (Owner/Agent). („ `�`" r Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 02()1. J J0 TRACT
1114M *31M WoJOB
SITE n n
ADDRESS 77 0A 44L
APN
X227' (; .E. NNMIN"A. 6-,F/ox
OWNER
CONTRACTO /DESIIGNER // EN (NEER
KA fi47VI
y✓NW.DA.SMWq
72.221 (-AL•TZXN_ 15J?NA3)A
7' 530 WFEL:J LWE 02:I MM lsaIN-17
IA (213MA 4A: 92253
LA C,2U:3AliTA CA 192233
(760)360.5405 rlsLO 461
USE OF PERMIT -
0MIUM, BILT.0 X90Z
rA.ST1A1 L C1,A..S"j A. URE;' KANIN' FOO.AM ROOF SYSTEMPYM,AITACM.G.O
CONTRACT.
RER."W3,090.Oin 10
X11 00 ' K7
x
tF
JAN 14 2002
CRY @Al�l��7f•TA
i
MAB-TXYTP17 CONISMMi:s•MOH 1iND
$30,00
• LESS Frz 6. k'SD PEV.`i
$0.00
RECEIPT
DATE ./
BY f/'
DATE FINALED
INSPECTOR'
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
BLOCKWALL APPROVALS
POOLS - SPAS
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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
��-� — .go Cf t/— l ��' O 2 Ap"L61
��l I D 92:80 too
SQ FT CODE TYPE CUVERING LAYEPS DESCRIPTION
L 340/2750 FLAT TAR & GRAVEL i -1- RE -ROOF
VAC TEAR -OFF DUMP PWR WA -CM LIFT A1C A/C PLAT ]FLASHING SDOB METAL SIZE
YES NO YEs NO NO NO NO NO "
NUMBER of COATS COLOR GRANULES COLOR BLISTER KEPAIRS 4'X8' SHEETING
-2- 1 WHT I NO I N/A I NO I YES
1TERMS: 10% DOWN / BALANCIE PMD UPON COMPLETION
Unless specked slope of roof will rrnain unchanged .Goose gravel and Xrt will be swept from roof.
secured gravel shall remain. All debris will be removed from premises unless otherwise ardvised. Any/tilt
"C'hailges" or discoveries di,ffiering from speeiflcadons included its this Contract may incur additional costs.
"Changes" to be paid upon completion of "ChaVoll Cawp"on of the rvoftrrg application will be a f acted
by weather conditions such as rain and wind Foam Masters can not guarantee removal of all water
standing on flat roof areas unless specified. New Roofs meal conform to 1997 Uniform Building Codes
eoncernine adequate Ovinam All new edet melt l to bt installed unpainted unless atimewise specrfi d. _
5 -YEAR NO LEAK WARRANTY*
Foam Masters warrrrtds to the BuiWig Owner (current and fututw) that, subfecl to the provisions of tins document,
Foam Mwtem Wu ar Aar aws s arwma4 ,oaths or comic tv be mads 411 repat►7 necessary to maintain the roofing &Stem
in a watertight condition Airing the five )war warranty Feria! folloving tAw data of complettox of Me roofing 'quis n.
System htdiedrs: MembranesMle butalled by fibam Masters, Flashings (except metal or cornpor+ends not included by
Fonts Afasterar as purl of its specified roo's)stem), Fasteners tied AdhesJwx Lindw1o". Foa►n Mastery liability
under this `rarraaty shall be limitad to the Owner's original eovt Q( the houttled roof ayslem and only Y' leakage is
cowed by defects In materials andlor workmto ship. Ezoltt.9innc: Damage to any part of the building (other than the
roof syrtein), lktnn V twultnng from: Reptilia or wcnrliperformed on or'near the roof without Foam Mmtero prior
authorization. D iaiaga frame awslaswnt expansion, contraction, ivarping, or nroueMent of the roof deck walls.
structrdrol menrbero or building foundation. Natural dtraeters (f3m, wimislorrn, halt, lightning, earthqut* etc). New
in ttallatlorrs on, t nwh or adfamnl to At roof system without Foam M. alters approve d. Ung omovilable events. Lack
of posili* "mage, Atruse or abuse of roof, tmpropar roof traffic. Failure 4fnwerialc (natallad by 01lMra (axeept
Jpecif ed roofsystenr)
* Repairs Only are mAided front the S- Year Warwettty and are provided whin o l- Year Warranty on repair area
ally (mon ens Carta &md ayet:ilic IsWetedpWrnta within aPttmwer r,odow), •10 -Year ftmm# wkea speed
#UL ICBG # 4630 UL # R10185
SCOPE OF PROJECT: All work will be completed in amor lanct with Manufacturer Specifications.
INSTALL CLASS "A" INSULATING URETHANE FOAM. ROOF SYSTLM
(Main House 2600 sq. i1. + 150 sq. ft. ductwork & Guest House 340 sq, ft.)
TO INCLUDE: Sweep and remove all ioosa gravel and dirt !tom root' surfaces. Spud
roofing at perimeter edge metal whore required, Remove 11W' ABS ,solar water heating system
from roof and haul away ($200.00). Apply neoprene primer to roof surface and A/C ductwork.
Lift A/C ductwork as required for roof application. Spray lVa" RT20.31 Urethane Foam to roof,
l" Urethane Foam to ductwork. Apply 2 applications Permax 108 Acrylic Elastorneric'Coating
System at 3 gals. per 100 sq. ft- over new foam (white finish).
GUEST HOUSE: $900.00 MAIN HOUSE: $7*420.00
Lift A/C and install 4$"x48" platform w/24 ga. galy. metal cover. 5600.00 additional + offsets
Cunsple+aou io aqs ager Amro or as ep"Ifled
ltnaftlls6on: Potfom►tuwe of specified work by foam
MAstars signi6aa your authorisation and s voemmt to pay jot
sad► work. All surplus mast Ws remain the property of
Foston Masters. Verbal a rcoeunts will not be birAng u*ss
set axile .herein or as speeifkd on a vVarsk ehta p otdcr. No
SIGNATURE OF CONTRACTOR
Contractors ole rcquireJ by low m be llecoved mad
regulated by dw Coatractors Stott Ueeou Board, which
bio juriadittlao to ia, tftflaaee eomplal"Is asslAst
contivet rw if •b nomplalat rFpr& ng a patient oca or
umbslon to filed Nithlo 4 mars a tbt date nr ttu "nn,..A