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0201-075 (MISC) 79722 Arnold Palmer m-------------- — ---•------------------------- LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMITk 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 t VALUATION Lor 0201-075 TRACT WProfessionals Code,and my License is in full force and effect. O :5 M License# Lic.Class Exp.Date r, Qin JOB SITE APN ADDRESS / t• 73315a 13 OaP 2/;2I ARNOLD PALMZ 7;2?- Or- Date I " Signature of Contractor + "-r ' / I { [• OWNER CONTRACTOR/DESIGNER/EN (NEER OWNER-BUILDER DECLARATION )?t.:A WFZr RF;3ZCiINYI L DNJ MAR PACWTIC C31+'1J'KI?Al,CON'TF'AM Wa I hereby affirm under penalty of perjury that I am exempt from the Contractor's ;:'(,3 BOAC 1060 2533 BC%LTTl1('0A,Y.I'1ILCi1NFAY TM 2,10 Cl) License Law for the following reason: ,(,A QUFi rA CA 92233 C'ARFt1) .1!';li 23JF Tt1J: 1 (4AA OiY") Z ( ) I, as owner of the property, or my employees with wages as their sole C' S s4-95UU ( ] >< 182.3compensation,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 MOCLU ANLOUS Code). () I am exempt under Section , B&P.C.for this reason 1t1U1121INCI 18•%5.7A79.71 1/9.714• VOLUNTARY STRUCTUI;'Al. 0 N Date Signature of Owner I tf fFiCA7f:al 1 rn (L Q WORKER'S COMPENSATION DECLARATION o1 hereby affirm under penalty of perjury one of the following declarations: F.Q. 0 ( ) 1 have and will maintain a certificate of consent to self-insure for workers' l+'.t IXAT)ON O,OOi1.0A LS X W LL compensation, as provided for by Section 3700 of the Labor Code, for the 00 _ Q pert rmance of the work for which this permit is issued. 100 Q U ( / I have and will maintain workers'compensation insurance,as required by 00 Q rn Section 3700 of the Labor Code, for the performance of the work for which this a F– permit is issued. My workers' compensation insurance carrier & policy no. are: Z Carrier a^D O STATE F UNE) Policy No. 04601UNI'1'000NIS :Kf+'T?.1l+LA.TIM COST OF CONb'INW7'HON 201W0.00 g (This section need not be completed if the permit valuation is for$100.00 or less). pERIF'1 TiC>3"11RY ( ) I certify that in the performance of the work for which this permit is issued; C7ONSTRUCJ ION FEF 101.000.418-CIOO a !10704 I shall not employ any person in any manner so as to become subject to the aPR0140 MOTION JOKE•RESID 101-000-7.d1-000 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 foirthwith 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 addition to the cost of compensation,damages as provided for in Section 3706 ' f of the Labor Code,interest and attorney's fees. s t IMPORTANT Application is hereby made to the Director of Building and Safety --- _ _ _ - 1•, 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 51[7E-TOTAL CON9.1.RU't.^ ION &ND 1:'5.A4(''1_TR?, !$2C13),tJC any permit issued as a result of this applicaton agrees to,&shall, indemnify XU9 }'FtE..17 fJiakalU.iJU & hold harmless the City of La Ouinta, its officers, agents and employees. 2.Any permit issued as a result of this application becomes null and void if 1,A1A , , 5 1`1GWI, ,I 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 IIIIII VIII III I II IIII 1 certify that i have read this application and state that the above information is 54 • 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,)urposes. J r r / RECEIPT DATE / BY DATE FI ALED INSPECT Signature (Owner/Agent) Date __ -17 / / 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 OX 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 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.I. Smcke Detectors Temp.Use of Power Final Utility Notice(Perm) IIIIIII VIII III VIII IIII 55 IE 4 64 P.O. BOX 1504 No. 002707 Building 78-105 79-722 PLA QUINTAC Address CALIFORNIA 92253 Owner Mailing s'i71'11 'm BUILDING: TYPE CONST. OCC.GRP. - ' Address , +erx s11*srlfx 1s11 Tlrfsna A.P. Number City Zip Tel. VA3M r10W1Xt . 92264 569-2R2R Legal Description Contractor Project Description RE WEV HOW 33 B Address. City Zip Tela Sam State Lic. City jam" 2596 &Classif.288130 Lic.# '328 Sq. Ft.(M X77 No. No. Dw. Size Stories Units Arch., Engr., Designer New ® Add ❑ Alter ❑ Repair ❑ Demolition ❑ Address Tel. City Zip State Lic.# LICENSED CONTRACTOR'S DECLARATION I hereby affirm that-1 am licensed under-provisions of Chapter 9(commencing with Section 7000)of Division`3'6f the Business-and Prgfessions Code,and my license is in fulll''fo rce ..riand,- effect. -.. -,rriC.}_ V11,LIr SIGNATURE DATE _ JOW NER.BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following Estimated Valuation reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a - 4-4 4411 - 1%flnet permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also " requires the applicant for such permit to file a signed statement that he is licensed pursuant to -. PERMIT AMOUNT the provisions of the Contractor's License Law, Chapter 9 (commencing with,Section 7000) of a Division 3 of the Business and Professions Code, or that.he is exempt therefrom, and the basis for the alleged exemption. Any violation of Section 7031.5 by'any applicant for a permit Plan Chk. Dep. subjects the applicant to a civil penalty of not more than five hundred dollars($500). " O I,as owner of the property,or my employees with wages as their sole compensation,will Plan Chk. Bal. ' 5-2-ra do the work,and the structure is not intended or offered for sale.(Sec. 7044,Buisness and Const. Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves .thereon and who does such work himself or through his own employees, Mech provided that such improvements are not intended or offered for sale. If, however, the building 5S.4111 or improvement is sold within one year of completion, the owner-builder will have the burden Electrical '#' ' ( of proving that he did not build or improve for the purpose ofsale.). ❑I,as owner of the property,am exclusively contracting with licensed contractors to con- Plumbing 32-5 struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for S.M.I. I-1A such projects with a contractors)licensed pursuant to the Contractor's License Law.) Grading ❑ 1 am exempt under Sec. B.&P.C.for this reason Driveway Enc. Date Owner Infrastructure WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insure, or a certificate of Worker's Compensation Insurance,or a certified copy thereof.(Sec.3800,Labor Code.) Policy No. Company ❑Copy is filed with the city. ❑Certified copy is hereby furnished. TOTAL CERTIFICATE OF EXEMPTION FROM REMARKS WORKERS'COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) valuation or less.) I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California. Date Owner NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become ZONE: BY: subject to the Workers' Compensation provisions of the Labor Code, you must forthwith Minimum Setback Distances: comply with such provisions or this permit shall be deemed revoked. Front Setback from Center Line Rear Setback from Rear Prop. Line CONSTRUCTION LENDING AGENCY Side Street Setback from Center Line I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code.) Side Setback from Property Line Lender's Name Lender's Address FINAL DATE INSPECTOR This is a building permit when properly filled out,signed and validated,and is subject to - expiration if work thereunder is suspended for 180 days. I certify that I have read this application and state that the above information is'correct. Issued by: Date ' "' I' Permit I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives sof this city to enter the above- mentioned property for inspeptidmpurposes. / Validated by: Signature of applicant 41 'el r / , Date Mailing Address Validation: City, State, Zip A 6 7 3 8 11 14 394, 95 U HARD COPY CONSTRUCTION ESTIMATE NO. ELECTRICAL NO. PLUMBING FEES 1ST FL. SQ.FT.® UNITS 2ND FL. SQ.FT. YARD SPKLR SYSTEM POR. SQ.FT.® MOBILEHOME SVC. BAR SINK GAR. SQ.FT.® POWER OUTLET ROOF DRAINS CAR P. I SQ.FT. DRAINAGE PIPING WALL SQ.Ff. DRINKING FOUNTAIN SO.FT.® URINAL ESTIMATED CONSTRUCTION VALUATION $ WATER PIPING NOTE:Not to be used as property tax valuation FLOOR DRAIN MECHANICAL FEES WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASH ER(AUTO)(DISH) APPLIANCE DRYER GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRY TRAY AIR HANDLING UNIT CFM KITCHEN SINK ABSORPTION SYSTEM. B.T.U. TEMP USE PERMIT SVC WATER CLOSET' COMPRESSOR HP POLE,TEM/PERM LAVATORY HEATING SYSTEM FORCED GRAVITY AMPERES SERV ENT SHOWER BOILER B.T.U. SO.FT.®c BATH TUB SQ.FT.®c WATER HEATER MAX.HEATER OUTPUT,B.T.U. SQ.FT.RESID®11/4 c SEWAGE DISPOSAL SQ.FT.GAR®3/ac HOUSE SEWER GAS PIPING PERMIT FEE PERMIT FEE PERMIT FEE DBL TOTAL FEES MICRO FEE MECH.FEE PL.CK.FEE CONST.FEE ELECT.FEE SMI FEE PLUMB.FEE 116- STRUCTURE PLUMBING ELECTRICAL HEATING&AIR COND. SOLAR SETBACK GROUND PLUMBING UNDERGROUND A.C.UNIT COLL.AREA SLAB GRADE ROUGH PLUMB. BONDING HEATING(ROUGH) STORAGE TANK FORMS SEWER OR SEPTIC TANK ROUGH WIRING DUCT WORK ROCK STORAGE FOUND.REINF. GAS(ROUGH) METER LOOP HEATING(FINAL) OTHER APPJEQUIP. REINF.STEEL GAS(FINAL) TEMP.POLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM WATER SYSTEM GRADING LUMBER GR. FINAL INSP. cu.yd. FRAMING FINAL INSP. $ plus x$ _$ ROOFING REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATION/SOUND FINISH GRADING _ FINAL INSPECTION CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURES/INITIALS. 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O [ m n y j ❑ " a m m o 3 w p a w [.] o a❑ c m a Q o a m _ c" S O 7 m = H cQ " ?10 -- cN2a rn5a 0(D @ - mmN m`Q °m vi w ° p m m om p RC1 ' m m d m m I. v'r M0Q 0m -m tc)w x tdmil m H ^] e c r "_ t -,z Q w x d z b r N Thi co < n o 0 >ub z Z O y O x n r Q ;J v rn z O -Di r r" o U N opIT m O co 'd z OD N+► G:a m [ri w r m D ' Z CrJ v m ' a m m cn ay — m ( i _— td G p O O W 110 01 a O C, (A cw7 O O O p O • " DAVE STEAVENS x y* Inspection Services r �.. PROJECT 4 w PROJECT # S + L LG ADDRESS _ -.4 c-. 5 / 7 _* ! b BLDG. PERMIT # ENGINEER l] o id 5'� dore-1.J C INSPECTION TYPE Page —L of of IIIIII VIII III VIII III 52 IE ';24'0a r o `l CLIENT _ ep A j J C JT oye-A DATE ARCHITECT tforeC i4 CONTRACTORSy L MA>Z. r'tN ti t - INSPECTION REPORT �'� ' �`� �] �� �J",>�G�l�rr'c 4 10C,7 L!'I 7 -7 - ') H1 A1x � JA A—y XJAIt,�! i 1. 3 y V4 S�'7 /Vt�r /'7 AA, i'Li2 ! • 14e;2 _ x rK 7C LIM b-- s — COO, LcT.:;7 �i i '� S ,[(ihJ%r�C� Ir ✓ L 7G� r5 ..�1� ��r4L%.rS rCJ�Lt t 7 LS''7 [vc.,ejai, Sowe .1�. NrfIc,OJG - �v►.+ r� a ;> 47—ria fir' 6tuCVi;l� �tL 4 _15'1 W [.-?u -- �M.3�• �L CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted, �- substantially complies with approved plans, specifications and applicable sections of the building codes. This report covers �l iho4owtions of % work inspected only and does not constitute engineering opinion or project control. CERT. NO. � J 5�`1 — INSPECTOR NAME .DA 74 DATE �Urtj C �fJ� Zi vrtC INSPECTOR SIGNATURE k-AL� • DAVE STEAVENS Inspection Services PROJECT �GN W C -!J - L C -<—E ,J ADDRESS 71! '7 ri 3 U PAc.Mt,tPlead i1'r Page of III IIIIII�lllllllllll 53 IE PROJECT # v 0ov� , kA3 C 5`C t� o ; CLIENT _ :; a A a L - -- DATE -T,-, QJ C BLDG. PERMIT # ARCHITECT (&.� L 3 fq 041?C ra ENGINEERNu. L;.� c -,f1 Jy , L: i aJ C- CONTRACTOR 1e:-1- M A (Z � INSPECTION TYPE INSPECTION REPORT 0 Ly -, F 7 - r,-1 AJA .rr rte+ c r t �,►� 7 CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted, substantially complies with approved plans, specifications and applicable sections of the building codes. This report covers the locations of the work inspected only and does not constitute engineering opinion or project control. CERT. NO. DATE INSPECTOR NAME INSPECTOR SIGNATURE A {Print Clearly]