0201-077 (MISC)79794 Arnold Palmer
LICENSED CONTRACTOR DECLARATION PERMIT#
U) 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 02011-077 TRACT
N W Professionals Code,and my License is in full force and effect.
License# Lic.Class Exp.Date
JOB SITE JA JCj APN
0 7331 S 3/31/i?LLJ ADDRESS If3FtItiT011)PALMM I /
GZ Date , Signature of Contractor OWNER CONTRACTOR/DESIGNER/ENGINEER
CD Or`
J U co OWNER-BUILDER DECLARATION PGA WM RFZMF14TW,ASSOCIATIOK DJr'I,MAR PACIFIC QE3dFlW,CO'r?77LAMYOR 9,J
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's gO:L OX 1460 2533 8OU11I COAST 1II0HW.AY STI:. 250
~ W License Law for the following reason: LA QMNTA CA 02253 CA.RI)IFY}3y'lRd g rEA M y2C10
Z_ ( ) I, as owner of the property, or my employees with wages as their sole (760)564-9500 mui 5821.1
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 IIIIIIIIIIIIIIIIIIIIIIIII
contractors to construct the project (Sec. 7044, Business & Professionals 3, 7ZCF.1._*T.ous 77
Code). IE
M () I am exempt under Section , B&P.C.for this reason 1"iR31t,IJInoA-019,7N,79485,79.714,79.rA-V01,12110?'ARY
N Date Signature of Owner STRUCTUTdA6l550DIMATIONS
ON
C7
CL Q WORKER'S COMPENSATION DECLARATION
p Cr I hereby affirm under penalty of perjury one of the following declarations:
Lo H O ( ) 1 have and will maintain a certificate of consent to self-insure for workers' VAWATION
X W LL 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 U Q Section 3700 of the Labor Code, for the performance of the work for which this
CL:
0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
ob D Carrier ^aTATE 1'/'YND Policy No. II460111JQT0DD%J3 WI.TIk'.4.A.iE'. )CM OF CONSr".[RUMON 291(M.00
t` O J?M?1t IT FRE fs`QIl4 KA: y
Q (This section need not be completed if the permit valuation is for$100.00 or less).
J ( ) I certify that in the performance of the work for which this permit is issued, CONSTRUCT10A M9 ICI-000-4]S-OW MOW
1 shall not employ any person in any manner so as to become subject to the STRONG NOTION FFF,•itlk."ID 101-000-241-W0 1 $2.00
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. x
Date: I - ' Applicant ' I! t I 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
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.
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 SC3I3 t CY'TA1,t%C3NM171t'' 014 AND PJ;,&'WL°+HpI.J!f<, W9.0
any permit issued as a result of this applicaton agrees to, &shall, indemnify LSI?I-SE, !'f l J S SU,(JL
& 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 .LQ,LAL KRm :5V
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
• 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 DATEFI ALED INSP CT
Signature (Owner/Agent) / ' Date'/= % ' I/ ' / ° 02
. _
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. Gnils
Fireplace T.O. Fans&Controls
Party Wall Insulation Condensate Lines
Party Wail 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 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)
IIIIIII IIIII III IIIII IIII 78
IE 4
P.O. BOX 1504 No. 002698
Building 78-105 CALLE ESTADO
Address 79-794 Arml. Palmier LA QUINTA,CALIFORNIA 92253
Owner
Mailing BUILDING: TYPE CONST. OCC.GRP.
Address 75,.M CbUntry Oub rriye„ . A.P. Number
CityZip Tel.
92260 568-2828 - Legal Description
Contractor Project Description PM TEW PH&W 13 E
'fit rWM1 z+rx4 P2 3D
Address
City Zip Tela
Sam
State Lic. City
&Classif. ,� Lic.# 3 Sq. Ft. DPW 2825 No. No. Dw.
M13Arch., Engr., Size QM 568 - Stories Units
Designer New X Add ❑ Alter ❑ Repair ❑ Demolition ❑
Address Tel.
City Zip State
Lic.#
LICENSED CONTRACTOR'S DECLARATION / y
I hereby affirm that I am licensed under provisions of Chapter 9(commencing-with Section
7000)of Di ton 3 of the Business and Professions Code,and my license is.in full force,annd
SIGNATURE "r Y' -DATE
/OWNER-BUILDER DECLARATION Estimated Valuation
I hereby affirm that I am exempt from the Contractor's License Law for the following �70'�!1 0"X��
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires-a - cis
permit to cons �
construct, after, 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) of
Division 3 oftheBusiness and Professions Code, or that.he is exempt therefrom, and the basis .plan Chk. De
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit p
'subjects the applicant to a civil penalty of not more than five hundred dollars($500). U9.10l
Bal.a. �].i�
O I,as owner of the property,or my employees with wages as their sole compensation,will Plan 10
do the work,and the structure is not intended or offered for sale.(sec.'7b44,Buisness and Const. 630.50
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,
M
provided that such improvements are not intended or offeredMech.
,for sale. If, however, the building. 455.00
or improvement is sold within one year of completion, the owner-builder will have the burden Electrical .71
of proving that he did not build or improve for the purpose of sale.) ,
❑ I,as owner of the property,am exclusively contracting with licensed contractors to con- Plumbing 136.50
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law y
does not apply to an owner of property who builds or Improves thereon, and who contracts for S.M.I. 12.36
such projects with a contractor(s)licensed pursuant to the Contractor's License Law.)
O I am exempt under Sec. -B.8 P.C.for this reason Grading
Driveway Enc.
Date owner Infrastructure 2„QQO.00
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. O Certified copy is hereby furnished.
TOTAL 3.485.17
V 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 personinany manner so as to become subject to the Workers'Compensation
Laws of California.
Dale Owner
NOTICE TO APPLICANT., If, alter making this Certificate of 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 hereby 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 if work thereunder is suspended for 180 days. * 1�s tt�fc�
I certify that I have read this application and state that the above information is correct. Issued by: Date ����a '�7tPermit
I agree to comply with all city and county ordinances and state laws relating to building r
construction, and hereby authorize representatives -of this city to enter the above- r
mentioned property for inspection purposes. Validated by:
Signature of applicant-foo'` +t .�' Date` f/^�' 1✓�
Mailing Address f ' Validation:
City, State, Zip
Ab / 41 11 14
HARD COPY
CONSTRUCTION ESTIMATE NO. ELECTRICAL F NO. PLUMBING FEES
IST FL. SQ.FT.® UNITS
2ND FL. SQ.FT.
YARD SPKLR SYSTEM
POR. SQ.FT.® MOBILEHOME SVC. BAR SINK
GAR. SO.FT.® POWER OUTLET ROOF DRAINS
CARP. SQ.FT.
DRAINAGE PIPING
WALL SQ.FT.
DRINKING FOUNTAIN
SQ.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 WASH ER(AUTO)(DISH)
APPLIANCE DRYER GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRY TRAY
AIR HANDLING UNIT CFM KITCHEN SINK
ABSORPTION SYSTEM. B.T.U. TEMP USE PERMIT SVC WATER CLOSET'
COMPRESSOR HP POLE,TEMIPERM LAVATORY
HEATING SYSTEM FORCED GRAVITY AMPERES SERV ENT SHOWER
BOILER B.T.U. SQ.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 ROUND PLUMBI UNDERGROUND A.C.UNIT COLL.AREA
LAB GRADEGROUGH PLUMB 2/ BONDING HEATING(ROUGH) STORAGE TANK
FORMS WER OR STI Y UGH WIRING i DUCT WORK ROCK STORAGE
QAr FOUND.REINF.I/ eliAS(ROUGH) L/—�..�� METER LOOP HEATING(FINAL) OTHER APP./EQUIP.
,�LREINF.STEEL` 1 GAS(FINAL) TEMP.POLE
GROUT WATER HEATER SERVICE Lit
NAL INSP.
BOND BEAM WATER SYSTEM
GRADING
LUMBER GR. FINAL INSP. cu.yd.
y,?`FRAMING 2 �2 INAL INSP. 2/!�� d $ plus x$ _$
O�ROOFINGQFU` _ s REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING ZV
MESH
INSULATIONISOUND
FINISH GRADING o�
INAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL