0201-077 (MISC)79770 Arnold Palmer
I hereby affirm under penalty of pery'ury that I am licensed under provisions of
BUILDING PERMIT -
H Chapter 9(commencing with Section 7000)of Division 3 of the Business and DATE VALUATION Lor 0201-077 TRACT
04 W Professionals Code,and my License Is in full force and effect. j
O 5 M License# Lic.Class Exp.Date
{` 0 r JOB ADDRE
SS
S APN
IX r` s 31 s n ; : ; 313110 A M01.0 z w x: 79- 770
d z r-Date Signature of Contractor i / / r f OWNER CONTRACTOR/DESIGNER/EN (NEER
O P_
J U OWNER-BUILDER DECLARATION PGA WMRF"Fk,MAr,ASSOCIATION DFt,WR PACWIC C3YMMAL COWMAII71VA 8,1
W WI hereby affirm under penalty of perjury that I am exema. pt from the Contractors R)BOY, 1060 2$33&X111I C; AS1"T1'tOkIW.AY':rl BSU
CO) License Law for the following reason: LA QVfIN A CA 92751 {;7•(t}lD.1FF}3Y 7°HL 81±:A CA 92007
Z_ ( ) I, as owner of the property, or my employees with wages as their sole (760)564-9500C'PI # 5823compensation,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 IIIIIIIIIIIIIIIIIIIIIIIII 48
contractors to construct the project (Sec. 7044, Business & Professionals 1 IASCEU T2EMS
Code).
() I am exempt under Section , B&P.C.for this reason f3U1l,L)1t C9 -794,79.784,'79-rA4.79•/'!0-VOLUNTARY IE
O rn .' Date Signature of Owner ST R1ICTUIRA1bMV)01MC'.ATIONO
(.5
Z WORKER'S COMPENSATION DECLARATION
EL
o Q cc I hereby affirm under penalty of perjury one of the following declarations:
r F- O O 1 have and will maintain a certificate of consent to self-insure for workers' V•A1.U.ATIO}i 2fJ,D0i1.i7v i,S
X W 11- compensation, as provided for by Section 3700 of the Labor Code, for the
m0 J Q performance of the work for which this permit is issued.
Q V I have and will maintain workers'compensation insurance,as required by
O Q SeZKion 3700 of the Labor Code, for the performance of the work for which this
0: 0) H permit is issued. My workers' compensation insurance carrier & policy no. are:
Iq Z
Cartier pp 1 Policy No.
cb 5 STATE' FlYND 0460111)411T►t►MIS +S111A A' ';11))(110ir'(Ar(:4?f€ lTtG7C`I.YOt°i 21),p()(3
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, MISTRUC'T1014 FFE 101-000-419-000 t,207.00
I shall not employ any person in any manner so as to become subject to the STRONG 140TION n;I?.gksi 'e IU3-oco241-(1Clu r x1 De!
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 shpll forthwith comply with those provisions. /
Date:1, Applicant I Z A
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
46 of the Labor Code,interest and'attomey's fees. r
I . • ,
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 SI)BI-IT)`tA-L 0,'0Hi'JT t.XX?!1C>? . ND Pl..;,fI4CR—!Ak
q P P , lQ. 1O
any permit issued as a result of this applicaton agrees to,&shall,indemnity 1.xV3 k'Rts.'fflb k7l 6 U,GtLti
ICU & 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
work is not commenced within 180 days from date of issuance of such TOTAL PERAUITENS DIKE NOW ;S209/J0
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
• 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
the above-mentioned property for inspection purposes.
/ RECEIPT DATE BY DATE FI ALED INSP CT
Dat
Signature (Owner/Agent)—=T—( /i a'
a-,
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
10
Final
f Final to 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 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.
Smoke Detectors
Temp..Use of Power
Final
Utility Notice(Perm)