BWFE2017-021078-495 CALLE TAMPICO Td4/ D Zfv Qai& VOICE (760) 777-7125
LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7011
DESIGN & DEVELOPMENT DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING PERMIT
Permit Type/Subtype:
WALL/FENCE/CITY STANDARD/PRE-APPROVED
Owner:
Application Number:
BWFE2017-0210
MAYELY MEJIA
Property Address:
53133 AVENIDA RUBIO
630 S GRENFALL RD APT 5
APN:
774042019
PALM SPRINGS, CA 92253
Application Description:
MEJIA / 88LF BLOCK WALL
Property Zoning:
Application Valuation:
$88.00
O ___
Applicant:
Contractor:
IVAR ENSMINGER
NOV 1 5 2017
OWNER BUILDER
53133 AVENIDA RUBIO
LA QUINTA, CA 92253
CITY OFLAQUINTA
COMMUNITYLIEVELOPmEEN'r DEPARTMENT
'
LIc. No.:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 ofthe Business and Professions Code, and
myLicense is in full force and effect.
License Class: License No.:
Date:
Contractor:
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State
License Law forthe following reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve, demolish, or repair any
structure, priorto its issuance, also requires the applicant forthe permit tofile a signed
statement that he or she is licensed pursuant to the provisions ofthe Contractor's State
License Law (Chapter 9 (commencing with Section 7000) of Division 3 ofthe Business
and Professions Code) or that he or she is exempt therefrom and the basis for the
alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
u. Es the applicant to a civil penalty of not more than five hundred doilars
as owner ofthe 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 and Professions Code: The Contractors' State License Law does not
apply to an owner of property who builds or improves thereon, and who does the work
himself or herself through his or her own employees, provided that the improvements
are not intended or offered for sale. If, however, the building or improvement is sold
within one year of completion, the owner -builder will have the burden of proving that he
or he d not bulid or improve for the purpose of sale. ).
as owner.of the property, am exclusively contracting with licensed contractors to
co struct the project. (Sec.7W, Business and Professions Code: The Contractors' State
License Law does not apply to an owner of property who builds or improves thereon,
and who contracts for the projects with a contractor(s) licensed pursuant to the
Contractors' State License Law.).
l am exempt under Sec. .C. for this ason
DatO: Owner = —
CONSTRUCTION LE_ iNGA
I hereby affirm under penalty of perjury that there is a nstruction lending agency for
the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Na
Lender's
Date: 11/15/2017
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one ofthe following declarations:
I have and'will maintain a certificate of consent to self-insurefor workers'
compensation, as provided for by Section 3700 ofthe Labor Code, forthe performance
of the work for which this permit is issued.
I have and will maintain workers' compensation insurance, as required by
Section 3700 ofthe Labor Code, for the performance ofthe work for which this permit is
issued. My workers' compensation insurance carrier and policy number are:
Carri Policy Number: _
I certify that in the performance ofthe workfor which this permit is issued, I
shah n '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 tothe
workers' compensation provisions of Sects ofthe • boriCodh
comply with those provisions.
Me: / Applleaat. --- � 1
WARNING: FAILURE TO SECURE WORKERS' COMPE SATION E IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($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.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT: Application is hereby made to the Building Official for a permit subject to
the conditions and restrictions set forth on this 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 application, the owner, and the applicant, each agrees to, and shall
defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and
employees for any act or omission related to the work being performed under or
following issuance of this permit.
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 county F
state Taws relating to b
construction, and hereby authorize represof this city to ter u a ov
mentioned property for inspection purpas
Date:[�•Signature (Applica nt :
r
Date: 11/15/2017
Application Number:
Property Mdre'ss:'
APN:
Application Description
Property Zoning:
Application Valuation:
Applicant:
IVAR ENSMINGER
53133 AVENIDA RUBIO
LA QUINTA, CA 92253
BWFE2017-0210
'. 58183 AVENIDAAUBIO
774042019
MEJIA / 88LF BLOCK WALL
$88.00
Owner:
MAYELY MEDIA
630 S GRENFALL RD APT 5
PALM SPRINGS, CA 92253
Contractor:
OWNER BUILDER
Llc. No.:
Detail: 88LF OF 6' GARDEN W/2' RETAINING ON SOUTH PROPERTY LINE ItITY SPECIFICATIONS] PRECISION CONCRETE BLOCK SHALL BE COVERED WITH
STUCCO, PAINT, OR TEXTURED COATING WHERE VISIBLE FROM OUTSIDE THE PROPERTY. THE AREA BETWEEN THE BACK OF CURB AND ANY FENCING
SHALL BE LANDSCAPED, HAVE A SUITABLE PERMANENT IRRIGATION SYSTEM, AND BE CONTINUOUSLY MAINTAINED BY THE PROPERTY OWNER. 2016
CALIFORNIA BUILDING CODES.
FINANCIAL INFORMATION
DESCRIPTION ACCOUNT
CITY
AMOUNT
RETAINING/COMBINATION WALL EA 50LF
101-0000-42400
0
$31.20
DESCRIPTION
ACCOUNT
QTY
AMOUNT
WALL/FENCE - FIRST 100 LF
101-0000-42404
0
$52.01
DESCRIPTION
ACCOUNT
QTY
AMOUNT
WALL/FENCE - FIRST 100 LF PC
101-0000-42600
0
$65.02
Total Paid for BLOCK WALL: $148.23
DESCRIPTION
ACCOUNT
CITY
AMOUNT
BSAS SB1473 FEE
101-0000-20306
0
$1.00
Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00
DESCRIPTION
ACCOUNT '
QTY
AMOUNT
RECORDS MANAGEMENT FEE
101-0000-42416
0
$10.00
Total Paid for RECORDS MANAGEMENT FEE: $10.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
TECHNOLOGY ENHANCEMENT FEE
502-OQ00-43611
0
$5.00
Total Paid for TECHNOLOGY ENHANCEMENT IFEE: $5.00
Twit 4 4 a"
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
(760) 777-7012
FAX (760) 777-7011
Considering Becoming an Owner -Builder?
Important information you need to know BEFORE pulling your permit!
The term "Owner -Builder" can mean three different things:
"Owner as Worker", "Owner as Contractor" or "Owner as Employer"
Understand each has Benefits or Risk, and it is possible to combine them!
Hiring a California Licensed Contractor means you do not personallyper orm any of the construction work, the permit is not taken
out in your name, you are not personally responsible for the construction and you are not an Owner -Builder. Instead, you become a
-Customer" and California law provides you the benefit of protection from poor workmanship, failure to finish the job and fruancial
risk due to worker injury.
Benefit/Risk: Hi9whest Benefits said the Least amount of Risk
Owner -as -Worker is a type of Owner -Builder where you personally perform the construction work, the permit is taken out in your
name and you are personally responsible for the construction management, knowledge, workmanship, and completion ofthe job, You
benefit by not paying others to perform this work for you and your risk depends on your own ability to complete the job successfully.
Benefit/Risk: Possible Benefit with Low Financial Risk
Owner -as -Contractor is a type of Owner -Builder where you personally act as your own General Contractor, the permit is taken out in
your name and you hire California licensed sub -contractors to perform portions of the construction work. WARNING: The benefit of
protection provided by law when you hire only California licensed sub -contractors can turn to serious financial risk if you hire
unlicensed contractors to perform any of the work
Benefit/Risk: Possible Benefit and Siznificant Financial Risk
Owner -as -Employer is a type of.O-Amer-Builder where you pay any unlicensed individual to perform anv construction work valued at
more than $500.00, the permit is taken .out in your name and you are. personally responsible for their employment requirements,
supervision, performance, safety and welfare while on your property. WARDING: Cost savings benefit can t='to serious financial
risk if you fail to deductpayroll taxes or provide workers compensation insurance for each worker.
Benefit/Risk: Possible Benefit with Significant Financial Risk
(Health and Safety Code Section 19827) The California Legislature declares an "urgent and statewide
public interest in assuring" that contractors comply with Contractors' License Law, Business and
Professions Code and Workers' Compensation Insurance requirements to ensure property owners are
informed about, and protected from the following when improving their property as Owner -Builders:
Fraudulent representations R Liability for worker's injuries - Liability for material and labor costs unpaid by
contractors - Licensing requirements - Employers tax liabilities
Over 20,000 consumer complaints are filed each year. Many complaints relate to owner/builder projects
and include workmanship and workers' compensation issues Homeowners suffer financial harm due to
defective workmanship and injured employees.
Following are alarming examples of what has occurred with Owner -Builder permits:
Example 1: Homeowner received insurance money to rebuild burned -down home.
■ Owner/Builder permit pulled to rebuild structure.
■ Unlicensed contractor built substandard structure — must be torn down and replaced.
• Estimated financial injury is $225,000.
Additional financial injury - IRS threatened to tax insurance payout if house not completed by the end of
the year.
Example 2: Brother-in-law had active license but fled an exemption from Workers Comp.
• Owner -Builder hires brother-in-law to install a new roof.
• Employee falls and sustains multiple spinal and extremity fractures as well as a head injury and
remains in a coma to this day.
a The Owner -Builder, who has sold the home, is now a defendant in a lawsuit for reimbursement for
benefits paid to the injured worker.
Example 3: Employee of contractor without Workers Comp is hired by Owner -Builder to install septic
system and suffers injury that results in permanent disability.
• The Owner -Builder did not have a homeowner's insurance policy on the house against which to submit
a claim.
■ The Owner -Builder is now a defendant in a lawsuit for reimbursement for benefits paid to the injured
worker.
Did you know — unlicensed persons frequently have the property owner obtain an "Owner-Bui#der" building
permit which erroneously implies that the property owner is providing his or her own labor and material
personally?
Did you know — your homeowner's insurance may not provide coverage for injuries sustained on your
property by an unlicensed contractor and his/her employees?
Did you know — if you are considered an "employer" under state and federal law, you must register with
the state and federal government, withhold payroll taxes, provide workers compensation and disability
insurance and contribute to unemployment compensation for each "employee"?
Did you know — that if you fail to abide by these laws you may be subjected to serious financial risk?
OWNERS BEWARE AND CONSIDER -THE RISK BEFORE ACCEPTING FULL RESPONSIBILITY FOR
YOUR CONSTRUCTION PERMIT
P.O. BOX 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
004"
BUILDING & SAFETY DEPARTMENT
PROPERTY OWNER'S PACKAGE
(760)777-7012
FAX (760) 777-7011
Disclosures & Forms for Owner -Builders Applying for Construction Permits
IMPORTALT-! NOTICE TO PROPERTY OWNER
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 at
We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your
responsibilities and possible risk you may incur by having this permit issued in your name as the
Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each provision,
signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice
unless you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
DMECTIONS: Read and initial each statement below to signify you understand or verify this information.
1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder"
ding permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as
an Owner Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person
and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those
injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers
onmyproperty.
��I understand building permits are not required to be signed by property owners unless they are responsible for the
ca truction and are not hiring a licensed Contractor to assume this responsibility.
1. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect
myself from potential financial risk by hiring a licensed Contractor and having the permit flied in his or her name instead of my
own.
*.
s 1 understand Contractors are required by law to be licensed and bonded in California and to list their lic
and contracts. ense numbers on
erirut
—f�. I understand if employ or otherwise engage any persons, other than California licensed Contractors, and the total value
o my construction is at Ieast five hundred dollars ($500), including labor and materials, I may be considered an "employer"
under state and federal Iaw.
qr6'
em I understand if I am considered an "employer" under state and federal law, I must.register with the state and federal
ment, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment
compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial
risk.
t7. T understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential
tures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed
subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed
under contract with a licensed general building Contractor.
�. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any
financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue
Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California
Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-
800-32I-CSLB (2752) or www.cslb.cagov for more information about licensed contractors.
_ 1Q. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the
legally and financially responsible for construction activity
proposed ty at the following address:
4 1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all
a icable laws and requirements that govern Owner -Builders as well as employers.
42. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I
havrovided on this form Licensed contractors are regulated by laws designed to protect the public. If you contract with
someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss
you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also
important for you to understand that if an unlicensed Contractor or employee of that individual or fh-m is injured while working
on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors,
you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers'
compensation insurance coverage.
Before a building permit can be issued, this form must be completed and signed by the property owner and returned to
the agency responsible for issuing the permit. Note. A copy of the property owner's driver's license, form notarization, or
other verification acceptable to the agen�Y is required to Asa red when the permit is issued to verb the property
owner's signature. J
Signature of property owner
Date: l.S
Note: The following Authorization Form is required to be completed by theproperty owner only when designating
an agent of the property owner to apply for a construction permit for the 0wn.er-Builder_
AUMORTZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility. I hereby authorize
the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder
Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address: ! 3 - / 2 3 C/
Name of Authorized Agent: ^ U ry ,f Tel No 16,
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owne c address listed above and I personally filled out the above
O
information and certify its aF
��. i�gopy of the to river's license, form notarization, or other verification
acceptable to the agency is d to bep to the permit is issued to verify the property owner's signature.
Property Owner's Signa — Date: 5
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PLAN LOCATION
—133 A," '1 .
Project Desrrll:tioii: fool, Remodel, Add'i, E, lcct. Plumb, 1%lec h
APN #:
e,
Address: 5'3 'IJ?
c
City; ST, Zile: t {-
Telepbone:
Email:
Valuation of Project S � J
Contractor Name:
New SFD Construction:
Address:
Conditioned Space
SF
City,st Zip
Garage
SF
'r' lephorie:
Patio/Porch
SF
'mail:
Fire Sprinklers
SF
Mate Lic: B.Us-1;ic:
arch/tng Name:
Construction Type:
Occupancy:
kddress:
Grading:
-ity, St, Zip
"elephone:
Bedrooms: Stories
# Units:
.mail:
Mate Lic: City Bus Lic:
78495 CALLE TAMPICO
LA QUINTA, CA 92253
760-777-7000
FOOTING OPTION "A"
1
i'
6' MAX
-� FIN ISH�GRADE
-RETAINED
EARTH
2' MAX
3" MAX—}
FOOTING OPTION "B"
H4 HORIZONTAL REBAR
(USE BOND BEAM OL.00K)
#4 VERTICAL REBAR AT 24"
....- --. MAX. SPACING
- (REBAR IN CENTER OF CELL)
#4 HORIZONTAL REBAR CONTINUOUS
•-- AT 32" MAX. ABOVE TOP OF RETAINING WALL
(USE. BOND BEAM BLOCK)
NON -RETAINING PORTION OF WALL
_ B" BLOCK ........
(GROUT ONLY. CELLS WITH REBAR)
(2) - #4 HORIZONTAL REBARS
-- AT TOP OF RETAINING WALL
(USE BOND BEAM BLOCK)
f �
RETAINING PORTION OF WALL
8" BLOCK
(SOLID GROUT ALL CELLS) FINISH GRADE
/ OMIT HEAD JOINTS =RETAINED
FOR DRAINAGE - ------- EARTH
,rr (FIRST COURSE ONLY) ��. N�f
_ r
(3' -44 HORIZONTAL_ REBARS
r % FJ?Nw5Jjj GRADF
Illfi =[]li 4" LL
12"
I
I 4" --96" F ` #4REBAR �.
-- ^- AT 24" SPACING -
i $� CAWITI•I6" MIN: HOOKS AT ENDS FOR OPTION -137
�---- ... 24"
THE FOLLOWING INSPECTIONS ARE REQUIRED:
1) FQQTINQ: EXCAVATION TRENCH CLEAN WITH STEEL IN PLACE AND SUPPORTED
3" ABOVE AND AWAY FROM THE SURROUNDING EARTH/DIRT.
2) REBAR/PRE-GROUT; BOND BEAM REBAR AND VERTICAL REBAR IN PLACE -
INSPECTION PRIOR TO PLACING GROUT.
3) F(NAL: AFTER GROUT IS PLACED - PRIOR TO ANY DECORATIVE CAP PLACEMENT.
NOTES:
1) FENCE HEIGHTS ARE REGULATED — CONSULTZONING REGULATIONS
BEFORE BEGINNING CONSTRUCTION.
2) NO WATER COURSE OR NATURAL DRAINAGE SHALL BE
OBSTRUCTED.
3) ALL REBAR TO BE ASTM SPEC. A61 5. GRADE 40 MINIMUM,
4) ALL REBAR LAP SPLICES TO BE 24" MINIMUM.
1
6' MAX
r
3" MAX. l
2' MAX
4"
Dl
- -T.
ALL FOOTINGS ADJACENT TO
SLOPES TO BE AT LEAST 5' TO
DAYLIGHT AS S14OWN BELOW.
BOTTOM
OF 5' MIN.
F-OOTING
'SEE PAGE 2 FOR ADDITIONAL INFORMATION'
5) ALL MASONRY UNITS TO BE ASTM C-90 GRADE N. WESTERN RIVERSIDE COUNTY CODE UNIFORMITY PROGRAM
6) NOT DESIGNED FOR SURCHARGE LOADS FROM
VEHICLES OR STRUCTURES. I,°_r r� TAtq j 4 .�v QaWcv
DISCLAIMER:
ALTERNATE DESIGNS MAY BE POSSIBLE BLOCK WALL
WHEN PROVIDED WITH AN ENGINEERED }�
`-,-
ANALYSIS. USE OF THIS STANDARD DESIGN 4°111'�N ATOP 2' RETAINING WALL
IS AT THE USER'S RISK AND CARRIES NO P1IONLS (760) 777-7125 78-195 OAIIIA� TAMPICO
IMPLIED OR INFERRED GUARANTEE AGAINST I LA CTUINTA, CALIFORNIA.92233
FAILURE OR DEFECTS. PAX (760) 777-70I 1 Iop/201n CONI11UNITV DEVELOPMENT I)B17 Pncr•. 1 OF'2
REBAR PLAC-EM.ENT
I LLUSTRATI O N
(SEEPAGE 1 FOR SPECIFIC REQUIREMENTS)
(TYPICAL)
FOR THE RETAINING PORTION OF WALL
ALL CELLS TO BE GROUTED
"TYPICAL)
FOR NON -RETAINING PORTION OF NNALL
ONLY CELLS AND BOND BEAM COURSES
WITH REBAR TO BE GROUTED
(USE GROUT STOP MESH AS APPROPRIATE)
FOOTING OPTION A
DESIGN PARAMETERS:
ACTIVE SOIL PRESSURE (PSF) = 30
PASSIVE SOIL BEARING (PSF) =1 50
COEFFICIENT OF FRICTION = 0.25
ALL.OWABLF_ SOIL BEARING (PSF) = 1 500
WIND = SO MPH, EXPOSURE C
SEISMIC:
NA=1 .3. Nv= 1 .6, Z=0.4, SOIL PROFILE=SD
FOOTING OPTION B
-I-- (TYPICAL)
ALL REBAR SPLICES
24" MIN. OVERLAP
�--� (TYPICAL)
ALL REBAR SHALL HAVE A
MINIMUM OF 3" CONCRETE COVER
AT FOOTINGS
11 WESTERN RIVERSIDE COUNTY CODE UNIFORMITY PROGRAM
Tj CV
•r.
d. at ° aGL
BLOCK WALL
y�"}1
ATOP 2` RETAIN.ING WALL
111-ION1.. (7601 777-7125
78-195 CAIA E,'I'AMPICO
LA QUINTA. t~JII.IFORNIA 92233
FAX (760) 777-7011
io/�/ u�•i
con�taur+rn r�r>vr; or• Irirrruitrr.
rncH:3o :?
CITY OF LA GUINTA SUB-CONTR'ACTOR_LIST
JOB ADDRESS PERMIT NUMBER_ OWNER_f - - T_ YBUILDER
This forms shall be posted oil the jo1�_with tflc [�t=ilclir7t� lnslaectian C�rrcl at �sf[ times irti a saris �ictin�:s laco. Only persons appearing on this list or their employees are authorized to work
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work_ Failure to comply will result in a stoppage of work and/or the voidance
of buildiwi (hermit. For each applicable trade, all information requested below must be completed by applicant. "On File" is not an acceptable response..
--.::-
- ri raiirc C'i[y.L�
State .Gnntractar s:L�cer�sr.... - Wogkirs t'piii(yeiia;t�n;ait_ .� .. .
�ra[�Cf CEa.,szt�ca�zor�............::....<.-:..._:::;Cor3trac.44r:.::. ...:.:... --
Company Name Classification - License Number Exp. Date Carrier game Policy Number EExp.Date License Number6. Exp. Date
(e.g. A, B, C-8)' (xxxxxx) (xxlxxlxx) (e.g. State Fund, CalComp)(Fortrat Varies) xlxx) (xxxx) (xx/xxlxx)
12
STRUCT..STEEL (C-
ivinsaNY (c-9) - V ! S2L,yl
DRYWALL (C.8)
iiVAG (C:.20'f
E=l_ECr:rEtEi;Eli. {C_t[}} •; •_- _
C): ...
GLAZING (C-i7):..
SLwAGE DISP.'
FENCINI (C-13)
-LI1NI]5CAPING ;{G- 2I)
POOL (C-a:i)