0201-075 (MISC)79730 Arnold Palmer
LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
1 hereby affirm under penalty of perjury that I am licensed under provisions of
l`_ Chapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE VALUATION LOT 1-075 TRACT
c1l W Professionals Code,and my License is in full force and effect. j /(_) ,I
ELicense# Lic.Class Exp.DateAPN
aLO JOB SITE
r` 733 2 5 $ !. 0 ,3 12 ADDRESS ARKOLY)P3 .A/I. +M '1,F 73 a - -
oZ r- Date ' , i Signature of Contractor l l ( l 1 OWNER CONTRACTOR/DESIGNER/EN (NEER
O
OWNER-BUILDER DECLARATION r "
J U co POA W ', ',r S ENM ASL. AA¢iIZ TSA qtr' a '>dh i Ai.,i Q iRAC."t G: ,S
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's PO BOX 1060 2333 SO T .111 COAMXTCiMAY V&250
~
0—License Law for the followingreason: t '
:,{1 t, IXAE i (A' 9225a 'f RS l f Xs' 3rf ."", C..+' Q F
Z_ ( ) 1, as owner of the property, or my employees with wages as their sole (760)564-9500 C-TY-# 5823
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professionals Code). USE OF PERMIT
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
cY) () I am exempt under Section , B&P.C.for this reason HLf11,DINf?I8=79,73t;1 ,!2:5 19.134• V OLUWl4;RY STRL'fC,=#L a,
O N Date Signature of Owner MO'OMMATIONS
rn
d Q WORKER'S COMPENSATION DECLARATION
C) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
LO -- O ( ) 1 have and will maintain a certificate of consent to self insure for workers' 1A
X W u- compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
CD Q I have and will maintain workers'compensation insurance,as required by
O V Q Section 3700 of the Labor Code, for the performance of the work for which this
tl rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
1* Z Carrier Policy No.
Ob 5 YrATX MD 04601LtASIT0009413 C()b-r We C0111913d:eYCI:fOW 20"co .00
C3 PERAW FEE frUAWAIRYJ
(This section need not be completed if the permit valuation is for$100.00 or less). CONSTRUCTIOU PTF 101-000-418-000 *2040( ) I certify that in the performance of the work for which this permit is issued, T
I shall not employ any person in any manner so as to become subject to the STRCT40 hKO`PION?#.Ir,°.i7-1P„SID 101-0004,41-000 $7.90
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 forthwith comply with those provisions:1
Date: / %. f1 r. ' Applicants
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
of the Labor Code,interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety --'x—=-
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 %7P,-T TAL CONSTIt.CI'C`I'. ORJA.ND P1<..1 I Clxf?'YK $2,09.0
any permit issued as a result of this applicaton agrees to,&shall, indemnity q X 19S 'Ia1E- D XSEE1`1 SOXID
& 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 T 1C)'r'AL PE . TXf DVE NOW
work is not commenced within 180 days from date of issuance of such y >
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is I IIIIIII VIII IIIIIIII IIII 67
• 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. f
RECEIPT DATEJ / BY DATE F,HdALED INSPECT
f
Signature (Owner/Agent) f ` /` Date ^'''
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 APPROV SLS 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 F
Main Service
Sub Panels
Exterior Receptacles
G.F.I. , I
Smoke Detectors
Temp.Use of Power
Final
Utility Notice(Perm)
F
I IIIIIII IIIII III IIIII IIII
68
IE 44
P.O. BOX 1504 No. 002706
Address 79-730 ArMId PalmerLA QUINTA,CALIFORNIA 92253
Owner
Mailing Tim amipmw BUILDING: TYPE CONST: OCC:GRP.
Address 75-005 07antry Club nfv3 A.P. Number
City Zip Tel.
iii: nt 92260 560-2828 Legal Description
Contractor Project Description IM VMM FSAM 13 $
Natioml Vie and Limid PIM 30 (}
Address
' City - Zip Tel. '
;
State Lic. City usc M5
&Classif.Z6813O Lic.#328 Sq. Ft.(kR �$ No. No. Dw.
Arch.; Engr., Size Stories Units
Designer New.IN Add ❑ Alter ❑. Repair❑ . Demolition ❑
Address Tel. .�
City Zip State
Lic.# -
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing:w th Section
7000)of Division 3 of the Businessand,Professions Code,and my licenseAs n"full force.and
effect .r-1- �f -2 �X
SIGNATURE' •r' '` ,/ DATE
r OWNER-BUILDER DECLARATION Estimated Valuation .7e h Rn
I hereby affirm that I am exempt from the Contractor's License Law for the following 178v307.00
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
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).or
Division 3 or the Business and Professions Code, of-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`tive hundred dollars($500). 2 n
❑I,as owner of the property,or my employees with wages as their sole compensation,will Plan Chk. Bal. .10
do the work,and the structure is not intended or offered for sale.(Sec. 7044,Buisness and Const. 63
50
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, Meth. :J'��VL
provided-that such improvements are not intended or offered for sale. If, however, the building 00
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 of sale.)
71
❑ I,as owner of the property,am exclusively contracting with licensed contractors to con- Plumbing L36.so
struct-the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner or property who builds or improves thereon, and who contracts for S.M.I. ` 32.36
such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
Grading
0 1 am.exempt under Sec. B.&P.C.for this reason
Driveway Enc.
Date Owner Infrastructure 2,000.A0
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 3A(35.17
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 thg 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 or 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 heieby 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 it 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 n-13-36Permit
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 inspection purposes. f / Validated by:
Signature of applicant %I t /rte Date
Mailing Address �"' f / i Validation:
City, State, Zip f
A 6 7 4 3 11 14 X48517 R
HARD COPY
CONSTRUCTION ESTIMATE NO. ELECTRICAL NO. PLUMBING FEES
1ST FL. SO.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. SQ.FT.
DRAINAGE PIPING
WALL SQ.FT.
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 WASHER(AUTO)(DISH)
APPLIANCE DRYER GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRYTRAY
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
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 APP.IEQUIP.
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
GARDEN WALL FINAL