0110-233 (BLCK)H
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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
71157086 :1:3?3 t: l�/,1fft3
Date Signature of Contractdl��.-�..��—
�—1 .�.
f 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:
t� )" I have and will maintain a certificate of consent to self -insure for workers"
c6Apensation, 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 FIRE Policy No. iArC20I396.P
(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 sh ll forthwith comply with those provisions.
Date: : "lk Applicant 4/1 ,, ��^^``
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 daye 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) t _ Date
BUILDING PERMIT PERMIT#
O1:dU••213
DATE 10118/01. VALUATION n'16..5mo LOT TRACT
JOB SITE
ADDRESS 77 -M'S 'CC.i�J.Eei X l[ MANGO APN _
OWNER CONTRACTOR/DESIGNER/EN (NEER
COVE EGkLOPN.:d7, LLC C€.' biVrRUICM. 0)q DESIGH SY811148 INC
78.4.0I TU'GHil'iAY, 711, SI At l 112 P, Cf.111NOX 626
LA QrT.t'1ITA CA 97753 I,..A QUDTfA CA 92253
(760)77 1 -3593 OS 141.. 5830
USE OF PERMIT
USPECTM RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
3WLft NG APPROVALS
R{dECHAMCAL 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
Parry Wall Firewall
Exterior Lath
_
Drys 01- Int. Lath
Final
Finzii
POOLE -SPAS
_
L00X1Nr A LL APPROVALS
Set Backs • 2-O ( ��- —d---
!�
Footings
Steel
Electric Bond
Main Drain
_
Bond Beam
_
=So -p (
_
Approval to Cover
Equipment Location
i
Underground Electric
Underground Plbg. Test
Final
PP�� JCM0 �°�J',� OVALS
_
Waste Line_s _
I Gas Piping —
Gas Test
Electric Final
Heater Final
Water Piping
_
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
i
O.K. for Finish Plaster
Sewer Lzteral
Pool Cover
_
Sewer Connection
Encapsulation
Gas Piping _
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
CLEC7MCAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F. 1.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)