0201-075 (BLDG)79714 Arnold Palmer
LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
F_ Chapter 9(commencing with Section 7000)of Division 3 of the Business and DATE VALUATION LOT TRACT
N W Professionals Code,and my License is in full force and effect. +,y/ i✓J ,t C!
p License# Lic.Class Exp.Date JOB SITE
LU lB 2'S ' B ' CI IrS IIili ADDRESS ARKOIX ?A M tAPN _
c Z r` Date r 1, 1 Signature of Contractor .-:L_ / f { l OWNER CONTRACTOR/DESIGNER/EN INEER
0
J U tp i OWNER-BUILDER DECLARATION POIA 1}Mr RESIT)c 7TAL DF1 J AIZ PAMC MMT-Al,CONTR !JL:M
LU aW I hereby affirm under penalty of perjury that I am exempt from the Contractors 1-1.1 BOX I MCI 2533 SOUTH C0A%Tf 11:1100WAY•ZWE 250
Cn License Law for the following reason: CA 92233 fY1 ii lf IFFC?}gg!Ti 1F:r" (4 t~!>
Z ( ) I, as owner of the property, or my employees with wages as their sole (J (lD .SGU C`E9.2(kj 7
It 9f323
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
contractors to construct the project (Sec. 7044, Business & Professionals M13(3?JJ_ A1W10LJ3
Code).
cr) () I am exempt under Section , B&RC.for this reason BUILCi NO!8•%9-'130,74•'T. 2,'-,?9=71±!" VJI.UNTAITY STRUCTURAL.
C\JN Date Signature of Owner 11 C MPICATIONS
rn
d Q WORKER'S COMPENSATION DECLARATION
o 1 hereby affirm under penalty of perjury one of the following declarations:
H p ( ) 1 have and will maintain a certificate of consent to self-insure for workers' 1►ALLI.AT)GH 20,000.00 LIS
X W 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 ( h 1 have and will maintain workers'compensation insurance,as required by
O U Q Stiction 3700 of the Labor Code, for the performance of the work for which this
t?: LO Z permit is issued. My workers' compensation insurance carrier & policy no. are:
— CarrierZ
cb 5 STATE FU)IV Policy No. y18Alt0rd('!'1 0U 17s :tia3"Iv"Tim con f.)F cONSr7d'I arioN 20,000.00C7 PIIMIA k'FES S'iT.l1WARY
g (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, f°ONSTRUC71017 Y9F 101.000.418.000
1 shall not employ any person in any manner so as to become subject to the arRono MOTION FF.E•RASID 101-0011••7d1-O00
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 shall fo hwith comply with those provisions.,
Date: Applicant—
Warning:
pplicant 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 /'.,
t
addition to the cost of compensation,damages as provided for in Section 3706
of the Labor Code,interest and attorney's fees. f ; ;',. L,/ t
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 au -TC)TAL Cd2d TR.D'C'17ow.A.NU PJ.Ai i C 1-f-17CK
any permit issued as a result of this applicaton agrees to,&shall,indemnify - 1.1;:15 F'tE- 1,fJ p7 `i MOD
& 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 ► :RM7 •Xw35 D NOW
t+)►, y
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. IIIIIIIIIIIII IIIVIIIIIIi
1 certify that I have read this application and state that the above information is 49
• 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 J RECEIPT DATE , BY DATE FI ALED INSPECT
Signature (Owner/Agent) f j / '.' Date ' j/' 1 ` 1/' ' ,' __ ?i (. If?
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 8 Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall-Int.Lath
1 17 Final
Final POOLS - SPAS
BLOCKWALL APPROV LS 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
Utility Notice(Gas)
ELECTRICAL 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)