0111-053 (RR)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H ` Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
cel W Professionals Code, and my License is in full force and effect.
O =) ch License # Lic. Class Exp. Date
t-_ O n9820 C39 WIWI(
Z r-/ Date Signature of Contracto,\.+--�-
CD0 �e ,rir
r- I— 6~, OWNER -BUILDER DECLARATION
J U CID'^ -.
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 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).
cY) () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
0)
FL Q WORKER'S COMPENSATION DECLARATION
p IM I hereby affirm under penalty of perjury one of the following declarations:
Lo H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q I have and will maintain workers' compensation insurance, as required by
Q U Q /Section 3700 of the Labor Code, for the performance of the work for which this
d rn permit is issued. My workers' compensation insurance carrier & policy no. are:
v Z Carrier STATE FUND Policy No. 0040DIP85101
cb O
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 agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I �halltforthwith comply with these prfivisions_
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. 4-••
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.
,Signature (Owner/Agent ��}- "'�-- Dated 6 tc>
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BUILDING PERMIT PERMIT#
4A:� � � ••£1R's�
DATE 11A)7/2(. VALUATION $6,(MAK) LOT TRACT
JOB ADDRESS �.i"�Ys�
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
"WJE; GORHAM
FOAM MASTM,
52_525 FLIM.
775.10 M&ZL.D I ARE G42; pAtad D1, Rip" "
Y..AQUI14TA C& 02253
LAQUINTA CA :2253
(766)1,60-3405 LY1+.O 461
USE OF PERMIT
1.OWMA..9.i
R:NZOOF C.EaRM .A. iJtwI'mm LEGA—M ROOF SYSTEM
DROOP 1.s
P E AOOF FRE ' 101-tiOO-418-0:0
�J tI 140V o7 201 r, -
Ley t if. f1
. 110 q ME-PAM)."FES
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TOM rrpmrr IT171b, DIVE NOW
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RECEIPT
DATEf
B.Y-,,
DATE FINALE
INSPECTOR
Jf G�/
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i O
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
SteelCombustion
Air
Roof Deck
�
�U S
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
' BLOCKWALL APS OVALS
Final
POOLS - SPAS
steel
Set Backs
Electric Bond
Footingss'
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:
America's #1 Choice in Urethane Foam Roofing
74-894 Lennon Place A-2
Palm Desert CA 92260
760/360-5405 S 760/340-9317 fax
www.foammastersroofing.com
CUSTOMER
JOB ADDRESS
IRENE GORHAM SAME
52-525 EISENHOWER X ENSENADA
LA QUINTA, CA 92253
CONTRACT
Date 11/5/01
CA Lica#779820 C-39
SQ FT CODE TYPE COVERING LAYERS DESCRIPTION
2682 1 1 FLAT TAR & GRAVEL I -I- I RE -ROOF
VAC TEAR -OFF DUMP PWR WASH LIFT A/C A/C PLAT FLASHING EDGE METAL SIZE
YES I NO I YES I NO I YES I YES I NO I NO 7 "
NUMBER of COATS COLOR GRANULES COLOR BLISTER REPAIRS 4'X8' SHEETING
-2- 1 WHT I NO IN/A NO I UNKNOWN
TERMS: 10% DOWN / BALANCE PAID UPON COMPLETION
Unless specified slope of roof will remain unchanged. Loose gravel and dirt will be swept from roof,
secured gravel shall remain. All debris will be removed from premises unless otherwise advised Arty/all
"Changes" or discoveries d Tering from specifications included in this Contract may incur additional costs.
"Changes" to be paid upon completion of "Change". Completion of the roofing application will be affected
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 must conform to 1997 Uniform Building Codes
concerning adequate drainage. All new edge metal to be installed unpainted unless otherwise specified.
5 -YEAR NO LEAK WARRANTY*
Foam Masters warrants to the Building Owner (current and future) that, subject to the provisions of this document,
Foam Masters will, at its own expense, make or cause to be made all repairs necessary to maintain the roofing system
in a watertight condition during the five year warranty period following the date of completion of the roofing system.
System Includes: Membranes/Tile installed by Foam Masters, Flashings (except metal or components not included by
Foam Masters as part of its specified roof system), Fasteners and Adhesives. Limitations: Foam Masters liability
under this Warranty shall be limited to the Owner's original cost of the installed roof system and only if leakage is
caused by defects in materials and/or workmanship. Exclusions: Damage to any part of the building (other than the
roof system), Damage resulting from: Repairs or work performed on or near the roof without Foam Masters prior
authorization. Damage from settlement, expansion, contraction, warping, or movement of the roof deck, walls,
structural members or building foundation. Natural disasters (fire, windstorm, hail, lightning, earthquake, etc). New
installations on, through or adjacent to the roof system without Foam Masters approval. Uncontrollable events. Lack
of positive drainage. Misuse or abuse of roof, improper roof traffic. Failure of materials installed by others (except
specified roof system)
* Repairs Only are excluded from the S- Year Warranty and are provided with a I- Year Warranty on repair areas
oniv (repairs are considered specific isolated Points within a greater roof area). *10 -Year Warranty when specified
SYSTEM #9 ICBO # 4630 or ER -5289 UL # R10185
SCOPE OF PROJECT: All work will be completed in accordance with Manufacturer Specifications.
INSTALL CLASS "A" URETHANE FOAM ROOF SYSTEM
TOINCLUDE: Sweep and remove all loose gravel and dirt from roof surface,
dump gravel on South side yard area as requested. Spud roofing from perimeter edge
metal. Lift A/C unit and install new 46"x50" platform with 24 ga. galv. metal cover.
Apply neoprene primer to roof surface and ductwork. Spray 1 " RT2031 Urethane Foam
to roof and ductwork. Apply 2 applications Permax 108 Acrylic Elastomeric Coating
System at 3 gals. per 100 sq. ft. over new foam.
Completion 10 days after start or as specified
Installation: Performance of specified work by Foam
Masters signifies your authorization and agreement to pay for
such work. All surplus materials remain the property of
Foam Masters. Verbal agreements will not be binding unless
set forth herein or as specified on a separate change order. No
SIGNATURE OF CONTRACTOR
Contractors are required by law to be licensed and
regulated by the Contractors State License Board, which
has jurisdiction to investigate complaints against
contractors if a complaint regarding $ patent act or
omission is filed within 4 years of the date of the alleged