0206-059 (BLCK)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 1 Exp. Date
743118 B fv; I M0/2t
Date Y (ly ,D Signature of Contractor 4
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.
(VY 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 'STATE Kftd7) Policy No.' 1509716.99
(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 sofas to '&come subject to the
workers' compensation laws of California,. and agree teat if I should become
subject to the workers' compensation prvisions¢of Section 3700 of the Labor
Code, I shall ,forthwith comply with those rovislons
Date: Igf Q /y Applicant 3 v I j'
s l
Warning: Failure to secure Workers' Compensation coverage is,unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor -Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at `
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 186 days will subject permit to cancellation.
i` r
I certify that I have read this application and(statethat the above information'is
correct. I agree to comply witl1 all 65ty, andlillState laws relating to the building
construction, and hereby..authorize representatives, of this City to enter upon
the above-mentioned proper forMT
Ipectio4ni purposes.
Signature (Owner/Agent); / ! ' Dateif+ {f)1
:l_ ML- DING PERMIT 02PERMIT% =� Mti•
B..59
DATE VALUATION c24� LOT 9&9 TRACT , . BM
15 4
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JOB SITE ADDRESS i r . i i�� �.J � APN 773491-02-7
OWNER CONTRACTOR / DESIGNER / EN INEER
NIOU'DrIABINT COVE DEVLiOPIt<!CWI° imp Ek -1 i'i?.PMES
P-A,UviDWITER.:A° CA 9V2611 ,rD110 0A. 92,201
C160)3, -8913 031.6 499$
USE OF PERMIT
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FINANCE®EPT
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RECEIPT DATE /� BY:> DATE FINA�D�y 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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
/
Electric Bond
Footings 7
l ��
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
767
Underground Plbg. Test
Final(, -7
Gas Piping
PLUM BINr,
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
COMMENTS:
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)
MOUNTAIN COVE DEVELOPMENT, INC. ,
PO BOX 3578
PALM DESERT, CA 92261
v 760-771-1670 FAX 760-564-9591
D ECE
THE CITY OF LA QUINTA
JUN d
PLANNING DEPT. �a . /�
78-495 CAL LE TAMPICO `"'oE4vF
LA QUINTA, CA 92253
05/20/02
Dear Planning Dept.,
We at Mountain Cove Development, Inc. would like to get a jump start on a patio
wall while we are waiting for our plans to come out, about one week `from now.. The
address we would like to get a permit for is 52-685 Avenida Ramirez,
We do hope this will be acceptable.
' Sincerely, �%'•� .
Larry Shields, President `,•
O Planning Cotamisskmum;
C3 Ci�tC
ommu
6Z
tr MAI ,
Case No...�.
Exhibit
With Conditions ...�...► «.....•*•�•+•►
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