0201-077 (MISC)79778 Arnold Palmer
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
F— Chapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE VALUATION LOT 0201-07 T TRACT
W Professionals Code,and my License is in full force and effect.
C :5 M License# Lic.Class Exp.Date
P,- d 1n JOB SITE' APN
►I 7331 13 i 3/31A) ' ADDRESS t"01A)PALAM 7q' 7-7p -
Z -
( j OWNER CONTRACTOR/DESIGNER/ENGINEER O Date - Signature of Contractor ? 4 ! E: _J .
U OWNER-BUILDER DECLARATION PGA VIM RFMFkMAL,ASSOCIATION DE1,AFAR PACIMC OFNERAL CG1TMkC1nR 8,1
LU LUaW I hereby affirm under penalty of perjury that I am exempt from the Contractors F('o 140X l Ot;6 2533 SLYCI H C LAST I11GHWAY 6*11s. 250
co License Law for the following reason: LA QVIINlA CA 92253 920017
Z ( ) I, as owner of the property, or my employees with wages as their sole
compensation,will do the work,and the structure is not Intended or offered for (x60)564-9500 C` illiiit 3823
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 lad C3 f'w T 0118
Code).
O I am exempt under Section , B&P.C.for this reason t3tllt UIN:9 ii•'d54,'71+•;24,'1s?!y 79• '!0•V Ot.t). 'TAP,'
N Date Signature of Owner STRUCTURAL feP.ODIM'{CATIONO
O
a Z WORKER'S COMPENSATION DECLARATION
io Q 1 hereby affirm under penalty of perjury one of the following declarations:
F O ( ) 1 have and will maintain a certificate of consent to self-insure for workers' V'ALVATICtO 3U,OOii,tld !,q
X W !L- compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q 0 k/ I have and will maintain workers'compensation insurance,as required by
dSe Ion 3700 of the Labor Code, for the performance of the work for which this
0) HQ permit is issued. My workers' compensation insurance carrier & policy no. are:
IqZ Carrier
n5
aTATE FU I) Policy No. 046011INIT0009419 T+S-l. 1:, 1,'AIET)(Myr OF("O.E`d;b:Clz'E7 t".IIO 2(fpoo.00
g (This section need not be completed if the permit valuation is for$100.00 or less). PR SM&SAR3f
( ) I certify that in the performance of the work for which this permit is issued, l^o ..mucT1014 FFI)s 101.000-418,00 4 (►',4i1
shall not employ any person in any manner so as to become subject to the STR0NC1 MOTIG?'N FEE- Rk,ID 101-000-2A 1-000
workers'compensation laws of California, and agree that if I should become -1
3 subject to the workers'compensation provisions of Section 3700 of the Labor
Code,I shill forthwith comply with those provisions.. . ` ;r
Date: f!; Applicant
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
s of the Labor Code,interest and'attorney's fees.
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. 6
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 S!.1.0 1.r)'1`ltiT..C;Utd` `'1`fi.L'ii:'a`IC>1T:h1 T f T l.;APE° iFl"t . aQ d.f>n
any permit issued as a result of this applicaton agrees to,&shall, indemnity LOUYR. •j j' 3liu ES,
& hold harmless the City of La Quinta, its officers, agents and employees. d(
2.Any permit issued as a result of this application becomes null and void if
TOTAL T,EhIl,MYt,S )
w $209A10
work is not commenced within 180 days from date of issuance of such 0 _
permit,or cessation of work for 180 days will subject permit to cancellation. i IIIIIIIIIIIIIIIIIIIIIIIII57
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 IE
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes. r
r ; RECEIPT DATE BY DATE tFIA LED INSP CT
Signature (Owner/Agent) 4Dat Date1 ' ,}7 I' " { 7/
INSPECTION RECORD
OPERATION j 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 Eiectric
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:
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)
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