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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