0310-158 (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 Exp. Date
5
CV W7 0.1f3V2;
,'Date ► 1 t� Signature of Contractor-'�"'""� �-
A
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I.am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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:
Cartier FIRM At ERICAIN ST Policy No. TNN 02""2201.
(This section need not be completed if the permit valuation is for $100.00 or less).
O 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 provisiolns.
Date: r Applicant-
LJ
pplicant li
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 authorizdyrrepresentatives of this City to enter upon
the above-mentioned property for mspection'purposes.-w r
Signature (Owner/Agent) } Date l�
BUILDING PERMIT.PERMIT#
DATE -VALUATION LOT' TRACT
...
JOB SITEA�+r
ADDRESS -3.5 B
.'rs.`5 P LE REA ,
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
"93iC"F�. Z,pE'Fb.
ROOF TRM SPWi _TALTY,104'-C.
55-3 aS PIM A REAC.H
74-990 RUNAWAY BAY a` R.
LA QUh A CA. 92253 •
BERMUDA UU), 9S` ` C. 92.7.11
(-7601200-ooI1 Ghia# m.20
USE OF PERMIT
R&ROl; fr WITH CLAS& AL ]bfA'B°ff:PJ L S
'li'ALUA:xngo 2%650.00 LS
11FRO )F.P-79 4,91.000.418.000 L30,00
...........
nCT -14 2003 .
CITY OF LA QUINTS.
.
FINANCE DEPT.
S -OB -TOTAL Powen'lucr .,him FU\W cm, CK
$30,00
LFS3 M -PAID FE3w,9 .
$0.00
y ,
RECEIPT
DATE, tl-� .
BY1 f.
DA FIN
P R
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 Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:.
Jul -08-03 04:12pm From -QUANTUM INFO-D;CK LONG
_4
7072544085 T-61": P-01/01 F-433
00000
RTS
JR00 Tile Sp"iOlty. Inc.
etmtractoM Latah Lj�xm a A 210587
P.O. U' opt ) IZ57 Yalta Desert, VA V1255
AtiVN1) 760-�VUa11i11 1'NG 76WvicK�A8o1
A propoW submitted to: DICK LONG
Masilfins Addma.-
Job AddLf ew SS -355 PEBBLE BEACH LA QLTWTA, CA 92.253
fie: 4 fRX A.-Vtc '
Daatsriptidn of work to be Demsated: �n�i�e�' leo uPe/ /.F
owr'ALN Aw- RRQt if¢tICfD WYFt. - 1Z�
Mtff>J.t4wff; Eons wo ROOF jWD 015POM CL.L3W ANY OVrMRS AND ALL ORO YNO AREA-
WNIT.ALs. N13W CANT wNjo,1,A?Eam CANT At Ai.+LwA l AND L'R)C "rT WANBrMON3. J
WAll.ON1tLAYER MASS BA411b.
INXTALI. 7'M= LAYERS 40LASS Pt lY 6 HOT 3.&C PM
IMaT4LU Nbw Row rA *tv AND PO4 RTER MWAL
R AiL W?AL 3LWACE L
HP t MQV TWO L VS" MASS PLY TO 70CPOMD 54VIAL. f MUS SVAL040 TO RCDT.
tavr h6W OPM LAY= 7zoCAp AT WAxZ.YRANSrrtQM
%SASTW AMi WE" ALL TMMiNATLONS ANDCOAT %VMI vfuW{AJ;S-
C$AAJrt Jas VTE TO Oaf muz sTANDAU DS.
),TOT A.CCEIrED AST 30 DAYS THS PROPOSAL IS MILL AND VOID
fprosw In keeping w10% filOiQt: uy VAndwds: 1. TM5 gvezaRLOC dues rr" Caves' scq dsxfapgc to the interior = eaio6w on +which kho 100F
68 Ltpplted of dR=WXC to any PODMtfs tlrtits;•i C6 This Suar=tw dues not aaaysr daoafsf$C to roof 41ma m say cause beyond our coitbvk
Awltidws. VW not uxalttld 1W.. 01% IWInniag. wladAt0—., hailaorrry WVA==v or ot)= cquipe w=4 foot t1-ai�c uetn 904 %wtural ftat
or seerlesnent, qFaking or adw r attune of tbo roof desk, walls arc &Unda — of tbo bnikding an wluoh the cosi Is applied_ z. shau ld At
bocvme neee"My fes dw rtrafalas oonbachn to MENWM mmd/OW Reir swl Aay amoaaaa, coolie or boatuxg sFVti=VQX Or other
aquW==x, whi:rhitr m rrot an a ftuatual ch s'go is n3a& ffsrfosbyr swab vMx1, the cumOver undQnvb && that neittbc��r6RvTS (�fl-.W ftwwttr.
Lew) nbr the ifRvmUer as:s vow spy altbilill. f0f the pmarA= of Said tfgt►xpM 0M, 3. RTS 00eTILMtrUisky, lar -2 dols: na; ateoURC
pW ruepofasablltiy flor varwaetions of =donng code vioLltlow Of for the n pmir of arty s'mif*6is8 4areca unlimm wed in estimate a**
,row Com S249,2 13.% Tam paid CA eontptetion uNew o*mwise fspeeMod in the oont== If tri. aaoapwd in shirt,' dwv this
pao�pasax is iuonralid. A.�a arbditborlul Dost aaY=33.00 par sbuott cat plywood will tta Y p�wawd to be laplecmd.
Acccptances You axe hereby aunmyt=d to fformisb nll omicaats .>,rittun iiia !late eotMtraet co eoatiYiaats word LafEaffltioned 'u0. tlbe pnopo8al
anaract Lor which lhve agree to poly the aim WA a,c mond, in said p x ap".At. and e,000f dwg to tCfCooB 0"Cut (lnitital). If a
le*olg/s, caused by 4 in wae"=uaWp6 00MM wiihim I N yteats *go* date orappua dual, we will frepaix defects fl)" Cf
Mharm-
W It je uodeMccid am by tLs =Wpm=- of this prep -W yax RTS trroarrtlu apmk hr- t—,) to mala the umallatkarl;
sa mus troth pmlets wit2t Miens sbum herein mad tv pay our cbwae Sar ouch iw-Radon. Ymr aWno bo PW the ammWM
We=-lawh"Cin, which Will coy= the PAW of'said matenfials and tabor rbarse. 'This cshmaio is based oa a compltbe)ob =A MW
japhu 1mStisRtl:11 rely wrap= y of RTS (RocrTBO :ape i9w. coo.).. Velbol audermanding and fnW=nPelW writh rLpreses tatW► o Shall not
Nx bmAuut ll)Shu mi tophi bacM Tht9 Ghali bo as liabilW= fvr dclwo us, Or failure w oomnplcbo, d*li &vr or instnVatlaa of 017. nor
,osW at Wm bmvin mentiumd nw=bandim- if bate w fixe, , war. BWW=uC4U mgutstiaaa or &W beyond mW ombucl- AM
xhanzcs =ad* by ym in spoadkoUaW WrVin, a n,8 ad&t mml fooPAaUis arant be to ludod or eo ricd by thla
;Proposal, bwx Man be pn wided flbr un& r nPasate and mddiafaaa! order fxvra you. _2=11+nitiaai).
.Arteitrmion of DifspuW; Amy Conttaf WW or elaim afdWAS oat of or relating to tW IF oonttcacy or One bract tbter04 rhtau sailed by
ari t swr N0. acoan uaos with that Applicable Copstruadlaoi Industry AdAuntui Roles of the: Aaoomc A A Atratiaa Acc=Rtion which
aro in of x4 at tba doe the deMand far arbitxatd m is filed. A.lttdlp0l AM award based upon the s adcnoe pr"ouf*d by the pary(ics)
,Wb* do Zdoes) :fy0peafr DX4 pwocipata. NotwitassanditiB Coulfamr's tiEbt w arbiaaue, eontrumv does nut waive aay of its liar
A i�EtS
In on avant of da($Rlt by Client in pWme= Of file atf am due boreundcr, clicra msro4s 4o pay e+arfa AMIAC attocogWV *A's and
•teat tateafutrea is ooilrt®reiea with oolleOdOp oP said ctrrsotMfats rvAet>etat' or nut. fmrft is tiled. 1,0'0/s fppr xfaotali a•+dle� an aanaaal pr>rorntagc
:of 18.0% will be chaq*d on all p= dne acawam. Conuacw's am roQuin d by Waw to be iiccnwd rind :Rgukded by the Couttra0ce'a
state aefana ALq/ grsaadons oanOfBfCAirlg a e0sti0:1cttsz rosy be rem m the rt:Eistes aoYthe board Whmc :td4m3S is: C.vwlh cksrs 9taltc
l4aena w Hoard. 9$95 Gaathe Road BacranNIMN CA 958717. Mailing adda+t:cs: P.O. box 26000, Savramanto, CA, 95826.
The 2ftwsD pricm oafs ndidons ata sxdsbcuuy and are harxw araxptC&
Owner swaatw xed
±0W
Date:
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