9705-034 (REMODEL)55205 Arnold Palmer
LICENSED CONTRACTOR DECLARATION PERMIT# CONTROL#
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT 11701,5-034 5089
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT TRACT
04 W ,,U Professionals Code,and my License is in full force and effect. .51(497 SS,; IIO.IK#
License# Lic.Class Exp.Date
OLP I . 1 JOB SITE APN
LU t+Ei #.'ti7 13 I I C X31[0 ADDRESS 55-205 ARNOLD PALMER
r Z r- /Date Signature of Contractor OWNER CONTRACTOR/DESIGNER/ENGINEER
O
(0 F- rn OWNER-BUILDER DECLARATION IVA WEST MA:SIT'It AVSOCIA'I'1t.)A.t BOB# {)WARDS C011IUR!flON
W W-(O I hereby affirm under penalty of perjury that I am exempt from the Contractor's 1'4}•BU•"K !R$ 79-920 DIE'S"t A DIUVE
~ License Law for the following reason: LA QUIN'IA (*A 0225?-1516 LA t;UIN A ('A 022153
Z ( ) I, as owner of the property, or my employees with wages as their sole (7Ci0.177S-7N3 06110 1212
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044, Business&Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed IIIIIIIIIIIIIIIIIIIIIIIII
contractors to construct the project (Sec. 7044, Business & Professionals KAlt_117 59
Code). IE
() I am exempt under Section , B&P.C.for this reason ItI; L LA1St 114"4:i1Jt11tI.NIQLPS11
O N Date Signature of Owner
rn
a Z WORKER'S COMPENSATION DECLARATION
Q 0: 1 hereby affirm under penalty of perjury one of the following declarations:
F2 p O 1 have and will maintain a certificate of consent to self-insure for workers' V AIA WIT N Lo
X Lu : compensation, as provided for by Section 3700 of the Labor Code, for the
m Q performance of the work for which this permit is issued.
Q U ()K) I have and will maintain workers'compensation insurance,as required by
O 0 Q Section 3700 of the Labor Code, for the performance of the work for which this
0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
ob o TrX. VE FUND 1,?..997-14=1 ENTIztATEDCIONTO (XIINSTLUICTtDN
J
(This section need not be completed if the permit valuation is for$100.00 or less). '!+:+HMI! l+Ee.S 1.1 1\1 All A N
( ) I certify that in the performance of the work for which this permit is issued, PLAN 0i#'CK 1• d-
I shall not employ any person in any manner so as to become subject to the (ION'tT1,R1.4..11oN i7;t; tnt-tKlli,,!#i -!i(1ft 3i 4D+t
workers' compensation laws of California, and agree that if I should become +
subject to the workers'compensation provisions of Section 3700 of the Labor 61130#trL'at#t'r1L h#is 101•! l#} S;I (d00 5i5.ttU
`Code, [,shall fortwithcomply with those pro Isioris r , i'L1I1 1F1tNii.trlil's LQ1.-#j (}. #i -C1(k1 S'l'l.+fit)
+/Date: ' - r Applicant t ti - 4'4 4` " :.'11t,C>tdi#Att:i'4'$4IN FF -t:0NIM 1004W-24140) S.S0
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 P, 1 R-1'(-#'I'r}I.('t'N! :I'Ft KTION AND t PIAN rill ('K S17ri.!S
& hold harmless the City of La Quinta, its officers, agents and employees. LE SIS, 11RE-PAID 1'F FS S0.00 '.
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 MAY 0 6 1997
permit, or cessation of work for 180 days will subject permit to cancellation. IT)TAL PERMIT FSS K%011KNt)W S11746.15
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
CIn"5"0 F RA ►T
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
RECEIPT DATE 7 BY D E INALED INSPECTOR
/Signature (Owner/Agent) IV `.S Date '
.f
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 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
COMMENTS:
Final %�""T" "'"✓ Jam/ �,�
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)