0203-052 (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 ExpFDate
499608 C39 l
Date ` u 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 SIAT'19 WND Policy No. W-0•0000154
(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,,)hat if I should become
subject to the workers' compensation provisions"of•Section 3700 of the 'Labor
Code,, -,I shall foyrth.With comply with thjose„provi ions. .�".
Date: % , G Applicant v�~
BUILDING PERMIT PERMIT#
DATE Q� mit
r VALUATION $700M
7 r� 0 LOT TRACT
JOB SITE
ADDRESS "i;, Y A. YJR:N.l3Jfi�.i [c:i...� f �'�'l�� r�, APN
OWNER
53-205 AV1,541 JAIM. ME A
LA QUINTA
USE OF PERMIT
GIN ml;Lymw�pwa
CONTRACTOR/DESIGNER/ENGINEER
13 S qCM'I'
CA 92253 CUM Da: CAZA CA 92679
(947)888-1665 C;I Ut 492,7
ti,YYr��i'.11"i':.risse�Ai``'��'�ii ��1yfq�� � 7.��,E,�$�fsl�n'1Y'i�eti��cl�d>r:�ci+►��,i���,talc�i '.��e �i.,
I�.GC�7� L`•�ViY�lJ7 i �� �-i id�Y•.4F7J'f.l.ri ljV �.t L�`9?4.+(►"c�/NS+�.
1~2E.RMW
EYMAYED eon. oir
IrERMIp maExSIA0 Ayy
REROOF, , 9 101-000-418-000 530.00
Warning: Failure to secure Workers' Compensation coverage is unlawful �J
shall subject an employer to criminal penalties and civil fines up to $100,00
addition to the cost of compensation, damages as provided for in Section 3 A
of the Labor Code, interest and attorney's fees. F[ MAR U 6 2002
IMPORTANT Application is hereby made to the Director of Building and Sa ety
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 author'ize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
RECEIPT
Date"
(Owner/Agent)
MM-TOICKT. C01, M., RUMOR AND PIAW CTITW11,
1-8193 Prx-P&D MIS
Now
DATE / I BY� I DATE FINALED
"7
INSPECTOR
i901XIAW
=100
$0100
V30100
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
6 Z .
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final �' o
BLOCKWALL A PROVALS
Final
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 Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
niv F RX I.10. : 949 888-1665
LEHMAN ROOFING. INC.
13 SEACLIFF
COTO DE CAZA, CA 92679
TEL/FAX 949/888-1665
NAME IADDRESS
- --- ............. ........ _. _........ .......
RONALD HOUSTON
53-205 AVE. HERRERA
LA QUINTA, CA 92210
ITEM
REROOF
DESCRIPTION
JOB SITE: 233 A ST., SAN DIEGO
TEAR OFF EXISTING ROCK ROOF TO PLYWOOD
NAIL 2 LAYERS 30# FELT OVER PLYWOOD
INSTALL MONIER LITEWEIGHT TILE OVER COMPLETE ROOF
I INSTALL HIP, RIDGE, AND RAKE TILES WHERE NEEDED
I INSTALL BIRDSTOP METAL AT EAVES
INSTALL ALL NEW METAL FLASHING WHERE NEEDED
INSTALL CONCRETE WHERE NEEDED
OVER FLAT ROOF: NAIL 1 LAYER 28# BASE SHEET
INSTALL i LAYER SBS MODIFIED CAP SHEET OVER DECK
SEAL AND PAINT TO MATCH
CLEAN AND HAUL AWAY ALL ROOFING DEBRIS.
{ 5 YEAR LABOR GUARANTEE.
I
EXTRA: 92.25 A FOOT FOR ALL WOOD REPLACEMENT
Mar. 86 2002 —
PROPOSAL
DATE ESTIMATE NO.
12/19/'01 II 1288
NOTE: PAYMENT SCHEDULE TO BE DETERMINED UPON SIGNING OF PROPOSAL
RESPECTIVELY SUBMITTED
PROPOSAL ACCEPTED
DATE
VALID FOR 30 DAYS
PLEASE SIGN AND RETURN OR FAX YELLOW COPY. THANK YOU
CALIFORNIA STATE FUND} - WORKERS COMPENSATION INSURANCE:
SAVERS - LIABILITY INSURANCE
TOTAL. �
7,300.00
.I
Total $7,300.00