0401-352 (SEISMIC REPORT)79731 Arnold Palmer
LICENSED CONTRACTOR DECLARATION PERMIT#
N I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
I-
F- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
DATE VALUATIONmm LOT TRACT
c14Professionals Code,and my License is in full force and effect. /
O j th License# Lic.Class Exp.Dateh. j
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LO I Ric 03r3l/2C ADDRESS #7PALMER.
ff0TXsAPN
f' OWNER CONTRACTOR/DESIGNER/EN (NEER
Z Date 7a!
Z / Signature of Contracfor` --" -- J
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I-- I-- o OWNER-BUILDER DECLARATION '
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d I hereby affirm under penalty of perjury that I am exempt from the Contractor's L,A.QIJTlh TA C.P. 92253 CEi1 ,731,rFBY I'FI'E F; CA 92007
U) License Law for the following reason:
Z ( ) I, as owner of the property, or my employees with wages as their sole (760)645-1010 C, RI- 582,E
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 C# PIRAILDUff-DRICa
contractors to construct the project (Sec. 7044, Business & Professionals
Code). VOI.df11T.ARY SEISMIC RETROFIT
cr) () I am exempt under Section , B&P.C.for this reason
N Date Signature of Owner
ON
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IL Q WORKER'S COMPENSATION DECLARATION
C:) Z I hereby affirm under penalty of perjury one of the following declarations:
Lo Q oC 'V'ALUATION t 000.00 Irks
r F- O ( ) 1 have and will maintain a certificate of consent to self-insure for workers'
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 I have and will maintain workers'compensation insurance,as required by
O 0 Q Section 3700 of the Labor Code, for the performance of the work for which this
IOL 0) F- permit is issued. My workers' compensation insurance carrier & policy no. are:
`t Z Carrier STATEFUND . Policy No. 04601UNIT9009415, EY. ' ".AMN C 0,5*7 Cir''CONiSTRUC4.fdON 6R00.00
;5
J (This section need not be completed if the permit valuation is for$100.00 or less). CONSTRUCTION FREE 101.ODO.418.000 $91.00
( ) I certify that in the performance of the work for which this permit is issued, STRONG MOTI034 FEE°RRS1I3 101-000-241-000 $.60
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'compensation,provisions of Sectione;3700 of the Labor
Code, I shall forthwith comply with those proy4iions.
Date: t lT .•/m! APPlicant=-..f
• Warning: Failure to secure Workers'C pensation Eo/verage is unlawful and JAN 2 9 2004
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 CITY OF LA QUINTA
of the Labor Code,interest and attorney's fees.
FINANCE DEPT.
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 SUB 1'MAT,CON'SM JC'`10114 AM Y3j,"CI F-„M $31.60
whose request and for whose benefit work is performed under or pursuant to LESS PRE-PAID FIRMS $R00
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 :1°t7IAL i' V11'.k 11TES V .►.+ ;Now
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 application and state that the above information is 11111111VIII 11111111 IIII 65 t
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon IE j
the above-mentioned property for inspection purposes. L
RECEIPTDATE BY DATE FINALED INSPECTOR
Signature (Owner/Agent)-, / a • -0- Date 1 XFd. rf !-
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 APPROVALS steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Plbg.Test
Final I 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: 1
Final
Utility Notice(Gas)
ELECTRICAL APPROVALS
Temp.Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fodures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp.Use of Power
Final
Utility Notice(Perm)