0401-354 (683) (SEISMIC REPORT)79691 Arnold Palmer
LICENSED CONTRACTOR DECLARATION PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT G40I.-3!54
H _ Chapter 9 (commencing with Section 7000)of,Division 3 of the Business and DATE VALUATION00 LOT TRACT
C14W Professionals Code,and my License is in full force and effect. I r e' •
License# Lic.Class Exp.Date
d ,aa.,,
LU r 733152 1j.0C 0 3/1,11/2 ADDRESS V,691,5 4, RROLD 'F'IATI .1i ►. . .JOB SITE APN _
I !( '-' 4 -p-.. / OWNER CONTRACTOR/DESIGNER/ENGINEER
o OZ r– Dafe 1 Signature of Contractor
f– o OWNER-BUILDER DECLARA ION
PGA DF'L' IA Z `4£ 7C 2 7 1' "ON] 1CT S`1
—J 0 CID 1f9f0 1.533 9CUI C.OA`s`Ti3[u I'3Y'AY 1t •15L
LL1 W I hereby affirm under penalty of perjury that I am exempt from the Contractor's 2- „
H a T.A QT1%TA. CA 922.53 C"* TP'>:BY Tj CA 92007
U) License Law for the following reason:
Z_ ( ) I, as owner of the property, or my employees with wages as their sole (740)635^1010 CBVT 5813
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 gINERA,BURR}O
contractors to construct the project (Sec. 7044, Business & Professionals
Code). VOLUNTARY SZ11S.M1C RFTRID.DIT
ce) () I am exempt under Section , B&P.C.for this reason
LO
N Date Signature of Owner
d Q WORKER'S COMPENSATION DECLARATION
pZ I hereby affirm under penalty of perjury one of the following declarations:
u7 Q 'VALetl. .TION #,000,00 U
FZ p ( ) 1 have and will maintain a certificate of consent to self-insure for workers'
X W L= compensation, as provided fo'r by Section 3700 of the Labor Code, for the
O _.Q performance of the work for which this permit is issued.
m 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
rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
v Z Carrier STATE FUND . Policy No. 04601U1•iIT0 09415 XMTED C09f Or£",OTtiSMITf'T,10H
C) PEPAM.'r)RX 9UNIMARY
J
(This section need not be completed if the permit valuation is for$100.00 or less). CONSTRUCTION FEE 101-000-418.000 5 1,00
( ) I certify that in the performance of the work for which this permit is issued, ST.RC',3NG MOTION FEE•RESIT] 101-000-241-000
g0
1 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'compensation1 provisions of Section 37001of the Labor
Code,I shall forthwith comply with those provisi6ns.
Date: %f Applicant.-_____A_ -3 t l q .rte _ (1
• Warning Failure to secure Workers'Compensation coverage is unlawful and ((JJ
shall subject an employer to criminal penalties and civil fines up to$100,000,in JAN 2 9 20
addition to the cost of compensation,damages as provided for in Section 3706
of the Labor Code,interest and attorney's fees.
tlk
IMPORTANT Application is hereby made to the Director of Building and Safety CITY OF LAFINANCE:3 Pll TA
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 SM-TOTAL CONSTj2LTMON AND PLAN CT '_7,., $81.60
whose request and for whose benefit work is performed under or pursuant to LF.33 PRN,PAO FRES $0.00
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 TOTAL PEE °T)MRS DIM•RYN $81160
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.
I certify that I have read this applicationand state that the above information is I III III IIIII III IIII 80
correct. I agree to comply with all City, and State laws relatingto the building1
construction, and hereby authorize representatives of this City to enter upon I IE
the above-mentioned property..,foinspection purpose's. --— -- ---_
/ + RECEIPT DATEBY / DATE FINALED INSPECTOR
V Signature (Owner/Agent): Date lel
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 1
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 PI .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 OX for Finish Plaster
Sewer Lateral Pool Cover
Sewer Connection Encapsulation I
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
' 4
Final
Utility Notice(Perm) s