0201-074 (RER)79690 Arnold Palmer
------—-----------------
LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
COI hereby affirm under penalty of perjury that I am licensed under provisions of
04 W F- Chapter 9(commencing with Section 7000)of Division 3 of the Business and DATE ' ) VALUATION LOT 02201-0 74 TRACT
Professionals Code,and my License is in full force and effect. ( •: )f,;• 1aa f, xl.(
p ch License# Lic.Class Exp.Date
d In JOB SITE
UJ Jp // JPN
133152 11 (`,i: ?y12( ADDRESS e1DN()La7l'A.if.1V3:Er:le! / / 'CO L-91
Z Date t Signature of Contractor t OWNER CONTRACTOR/DESIGNER/EN (NEER
co0 "
r` 0 OWNER-BUILDER DECLARATION PGA VJF"S"!`RESIDEN1'1AL ASSC1(''IATfON DE1,MAR PA(00C E 047RAL !C+N'W.CX)•
V
H CL I hereby affirm under penalty of perjury that I am exempt from the Contractor's PID 1.0,x 100 2533 13UL'1TH C0IWI'l1.Kr1AVAY FIR 150
U) License Law for the following reason: LA QUfN'f'A CA 92213 CA:R)::Ili"1+R D.W.SYKA Ch 92.CKV
Z ( ) 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). USE OF PERMIT
as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals N3ISG"ELT N1±OU3
Code).
cr) () I am exempt under Section , B&P.C.for this reason E9tJ1Ir15INA 17. 79•i RG, Y9>643, 79:ti9(> ';'9•GISI•VOLUN f'.A1cY
0 N Date Signature of Owner14TR1,10.'FURALNiODIF1CAT10148
rn
d Q WORKER'S COMPENSATION DECLARATION
o1 hereby affirm under penalty of perjury one of the following declarations:
r Fa - 0 ( ) 1 have and will maintain a certificate of consent to self-insure for workers' VALUATION 2Q p0p 00
X W !L compensation, as provided for by Section 3700 of the Labor Code, for the
m J Q peance of the work for which this permit is issued.
rform
Q U ( I have and will maintain workers'compensation insurance,as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il rn H permit is Issued. My workers' compensation insurance carrier & policy no. are:
'IZ Carrier
n O 5 '1.A'f E:.Ft101) Policy No. D4601 UNIT! 0941 J ltiSi71MATXl1 CU1ii'Ulf t,'01VV77t1tf71I0P1 20,tMlt?,00
(This section need not be completed if the permit valuation is for$100.00 or less). b''ERNITT 11 ER(S1:TMNIARY
( ) I certify that in the performance of the work for which this permit is issued, Ct-WSTRUCTd!TH N'FL I - 101.000-418000 3!07,0!1
I shall not employ any person in any manner so as to become subject to the -'+ONCI MOTION ME..USID 101-000-24 1_(KX)
workers' compensation laws of California, and agree that if I should become
3 subject to the workers'compensation provisions of Section 3700 of the Labor
Code,I shall f rthwith comply with those provisioris.
Date:1 Applicant l ',j/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 i•r r
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 t I
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 SUB-TOTAL CON M. .T1Cf10N MA),41AN CM-ECK $209,0
any permit Issued as a result of this applicaton agrees to,&shall,Indemnify s 7,k k"# i: y (3 00
& hold harmless the City of La Quints, Its officers, agents and employees.
2.Any permit Issued as a result of this application becomes null and void If TOTAL PEINIJT M0 D101,NUI i20< fi
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. r- IIIIIIIIIIIIIIIIIIIIIIIII
1 certify that I have read this application and state that the above Information Is 02
• correct. I agree to comply with all City,and State laws relating to the building IE
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for Inspection purposes.
i RECEIPT DACE BYE^ DATE 71D1 INS
vZ PECTO
Signature (Owner/Agent) . FS Date 1 -2 i 1 `iJ r? 7" *
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 APPROVA,6 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:
Finalj�/�'V�r` //�L
Utility Notice(Gas) ✓��
ELECTRICAL APPROVALS
Temp.Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
Smoke Detectors
Temp.Use of Power
i
Final
tRility Notice(Perm)
r