0485 (COMB)-PERMIT APPLICATION
City of La Quinta
Department of Building and Safety
'This permit becomes void if work not commenced within 180 days from date of issuance. OR, if work has deen.susoended or abandoned for a'period of 180 days.
'CERTIFICATE OF EXEMPTION FROMWORKER S, CO MPENSATION INSURANCE: This section need not be completed if -
LICENSED CONTRACTORS DECLARATION: I hereby affirm that: I' am licensed under I prov isionsof Chapter g.,. the.permit'is toxone hundred ($100) o, less. I certify thatJn the performance of the work for,which this permit is', —
(commencing with* Sectidn, 7000):01 Division 3 of the Business and Professions Code, and my license is in full force issued. I shall not employ any person inany mannerso.as to become subject to the Workers! Compensation Laws of
and effect. California.
License Class Lic..Number. Date Applicant
Date- Contractor NOTICE40 APPLICANT: If, after, making this Certilicateof Exemption, you should become subject to the Workers'-
Compensation provisions of.the.Labor Code, you must forthwith comply with such provisions or this permit shall
OWNER -BUILDER DECLARATION: I hereby affirm that) am exempt from '
iile Contractor's License Law for.the be.deennid`revoke . d
following reason (Sec. 7031.5. Business and Professions Code, Any City orcountywhich requires a permit to
construct, alter, improve, demolish.'or repair -any structure, prior -to its issuance: also requires the applicant for DIVISION OFANDUSTRIAL SAFETY PERMIT CERTIFICATION:
such pprmi�t to.file.a signed statement that he is'licensedp.L�rsuanttothe,prqvis ioASLof theContreactor!sLic nseLaw 'Ol hereby certify th . at no excavatiorifi4(5)'or more feet in depth into'which a pRrsdn'is required to descend. will be*
(Chapter 9(commencing with section 7600) of Division 3 o the Business and Professions Code) or that he is exempt made & in connection with work authorized by this permit, and that no building structure, I scaffolding; falsework,'or
therefrom and,the.basis for the allegeq.exemption. Any violation ot.lSection.7031.5 by any -applicant -for a permit. demolition or dismantling thereof, Will 6e'more than thirty-six (36) feet hi6h.-(Ch40.2. GrpZ`Arf 2, Sec341, Title - 8,
subjects the applicant to a civil penalty of not more than five hundred dollars (5500.): C.A.C.)
E) I. -as owner of the property, or my employees with wages as their sole compensation, will do the work: and the
0 As -owner-tiuildu, I'Wili not employ anyorii 16'do work Which would require a -permit from the Division of
'.structure is not intended.or offered for sale (Sec. 7044. Business and Professions Code:.The Contractor's License Industrial Safety, as noted above, unless such person has a permit to do such-wbrk from. that. division.
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. provided that such improvements are not intended or, offered for sale.':If,-however;� the 0. Division of Industrial Safetypermil No
building or improverrint is sold within oneyear.ofcompletion. the owner -builder will have the burden.of-proving that - - - Date ADDlicant
he did not build or improve for the purpose of sale.).
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agencV.for the performance I k
10 1, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec:. of the work fof-which this Permit is issued (Sec: 3097.& Civ: C.);
7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of property who-.:-, . ". .:.
Lender's Name
-builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to'the,
Contractor's License Law.). Lender's Address
• 0 1 am exempt*under Sec. B. & P.C. (Attached Certificate). .;..I certify that I have read this application and state that the above information is correct. I agree to comply with all
Date Owner city and county ordinances and state laws.relating to building construction, and hereby authorize representatives
of this county to enter. upon the above-mentioned properly for inspection purposes. - -
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, ora
certificate of Workers' Compensation Insurance .,or a. -certified copy thereof (Sec' 3800. Lab! C.).
SigAiiure of Applicant or Agent Date
.Policy No. Company CERTIFICATE OF COMPLIANCE AND AUTHORIZATION, OF . ENTRY: I certify I have read this applicatiori and state that
.0 Certified copy is hereby furnished. the'information given is correct 1l agree to -comply with all state laws and county ordinances relating to�buidling
C, cnp.r . men or City Department. construction, and authorize a representative of the City of La Quintai Department of Building and Safety -to enter
Certified copy'is filed with the City Building lns�e 1 0 * I I V , -- upon
Applicant Pon the property : .lor which I have appliedf;r this p . ermil.for the purpose of making inspections: - -
Da 49AV - .
Signature of Applicant or Agent Date
APPLICANT NAME (L F MI)
ADDRESS
CITY/COMMUNITY/STATE/ZIP
,�� e,43o,4_1 CA
JOBSITE ADDRESSfS:PACE
-57,3-T1
CITY/COMMUNITY/STATE/ZIP
L.
BOK
PAG
PRC
C
TWN ..
RNG
SE. I.S
TRACT
LOT-
I
moo
I. SB
TRACT NAME
OWNER NAME (L. F. MI) -
'67, C 4,OAIAJ
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 11
s4l-716o
LICNC #
4//. T77
ARC/ENG FIRM NAME
•
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC 4
USE OF PERMIT
ZON
FSB'
SSB
SSB-.'
RSB
OFC':,.
ZONE ORD 0
LOT SZ
END
SIDE
w
Print Applicant/Agent Name
APPL/PRMT fl DATE 4 R S,
-5z-�c 6 0- 4o JZ'
7
Ir ZI-4�4 14�fCAV /7
,A
ToTAL
.,FEE
Sa
BLDG. -DEPT -i
VALUATION
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
34
Plenums'& Ducts
2A
Slab Grade
35
Furnace Compart.
3
Steel
36..
Inlets & Outlets
4
Grout Blocks
37
Combustion Air
5
Bond Beams
38.
Compressor
6
Roof Deck
39.
Appl. Clearance
7
Framing
40
Fire Damper
8
Vents
41
Smoke Detection Device
9
Garage Fire Wall
42
Commercial Hood
10
Fireplace P.L.
❑
43
Final.
10A
f=ireplace T.O.
❑
NOADDITIONAL INFORMATION
/�-1 -q -/
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
128 Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING APPROVALS
15 Ground Plumb
16 Water Piping
17 Rough Plumb
18 Vents
19 Sewage Disposal
20 Sewer
21 Water Heater
22 Water Softener
23 Water Service
24 Gas Test
25 Final
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
p/L P/I
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
296 Bonding
30 Fixtures
31 Service
32 Final