0201-077 (MISC)79786 Arnold Palmer
I hereby affirm under penalty of perjury 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 LOT 0201-077 TRACT
WProfessionals Code,and my License Is in full force and effect. (
C :3 M License# Uc.Class Exp.Date
W r ADDRESS APN
73313 n { :` 313110ARNOLD PALM
ZO r Date Signature of Contractor OWNER CONTRACTOR/DESIGNER/ENGINEER
J U co OWNER-BUILDER DECLARATION
PGA'WM1RFZMEtMALA88W1ATr014 M,MAR PACIFIC C3MMUd,CO:W17t MYO ,1
W WI hereby affirm under penalty of perjury that I am exempt from the Contractor's PO BOX 1060a. 2133 5011111 COAST HIGHWAY' 25
U) License Law for the following reason: LA QD1W17A CA 92253 CA-1t3 O'F BY THC?SEA CA 9200?
Z ( ) I, as owner of the property, or my employees with wages as their sole (760564-9580 C +I f+i 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 69
contractors to construct the project (Sec. 7044, Business & Professionals 3 WC:"E•1.:I-AAL-10118
Code).
LO () I am exempt under Section ,B&RC.for this reason BU11,U114C9 ;' 7 A94,751•'386,9.74y 79•r!0•V )l.tJVYAP,Y IE
N Date Signature of Owner STRUCTURAL MO131MCATIO7 41
O.
d Z WORKER'S COMPENSATION DECLARATION
uo Q Q I hereby affirm under penalty of perjury one of the following declarations:
O ( ) 1 have and will maintain a certificate of consent to self-insure for workers' VALVATIC10 2U,bElb.saG 1Z
X W 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 () I have and will maintain workers'compensation insurance,as required by
O 0 Q Sebtl on 3700 of the Labor Code, for the performance of the work for which this
a H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier
OD Q STATE FUND Policy No. I)46QIt1N01'ftGtt9 ils I+:1i'l:[.A A',!'C"'l?COM'OF C.O. S.M..'00,17.O,N 30111 11).00
g (This section need not be completed f the permit valuation is for$100.00 or less). p.ii !Q `F'801V>Lil/1A N_5t
( ) I certify that in the performance of the work for which this permit is issued, C0111STRUC"TIOA FE1 103.000-418.000
1 shall not employ any person in any manner so as to become subject to the LTRONO MOTION Fr@.F. d-mr) i02-Ull{1-?dA-Qt.1u
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 shell forthwith comply with those povisions.
Dater .1 ".Z - 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
` 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. '
L
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 n1.a1 •-;1. YI".J13.,( Utd 'C4.17i.'3°It>}7:t1AlI i?1,llE'F33 ;t. > 2 f)c2,fK}
any permit Issued as a result of this applicaton agrees to,&shall, indemnity LF&H PR* . ',A.*I IS MOO
& hold harmless the City of La Quints, its officers, agents and employees.
2.Any permit issued as a result of this application becomes null and void if °COTAI i,P ?j',1 `E,w 27t?W S2U' . 10
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 1
• 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
Signature (Owner/Agent) {— ; .1 - ' Date•', j/ '•' ► ` r T
Z
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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 I Gas Piping
PLUMBING APPROVALS Gas Test
Electric Final
Waste Lines Heater Final
Water Piping Plumbing Final
Plumbing Top Out Equipment Enc:osure
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)