0868 (SFD)i PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
JOB SITE ADDRESS/SPACE - - -
54-295 Obramn
CITY/COMMUNITY/STATE/ZIP •• • ; I
La Qu inata,. CA 92253
This permit becomes void if work not commenced within 180 days from date of issuance,.OR, if work has-been suspended or abandoned for a period of 180 days..
PAGPRC,
241
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
LICENSED CONTRACTORS -DECLARATION: I hereby affirm that I am ,licensed under provisions, of .Chapter 9.:
the permit is for one hundred ($100) o,.Iess..l certify that in the performance of the work forwhich this,permit is
(commencing with Section 7000) of Division Sof the Business and Professions Code, and my license is in lull force
' issued: I shall not employany person in any manner so as to become subject to the Workers' Compensation Laws of . .
.and eflecL /'� i r r
_� % ? ��
California. '
' ' ' '-Applicant
License Class � Lic: Number
Dal _/Z fZ' ? O i L� Contractor - Z
Date
.2, - NOTICE TO APPLICANT: If; after making this Certificate of Exemption: you should become subject,to the Workers'
• OWNER -BUILDER DECLARATION: I hereby affirm that*l am exempt from the Contractor's License Law for the
Compensation provisions of the Labor. Code,you must forthwith comply with such provisions or this permit shall... r -
'
' following reason (Sec. 7031.5. Business and Professions Code:. Any city or county which requires a permit to
: be deemed revoked
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
sucq:permit to file a signed statement -that he is licensed pursuant to the provisions of the Contractor's License Law-.
'p 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be,
(Chapter 9(commencing with section 7000) of Division 3 of the Business and Professions Code) or that he is exempt
made inoonnection with work authorized by this permit; and that no building structure, scaffolding, falsework, or
therefrom and the basis for the alleged.exemption. Any violation of Section 7031.5 by any applicant for a permit,
demolition or dismantling thereof, will be more than thirty-six (36) feet high: (Chap 3.2, Grp 2, Art 2, Sec 341, Title 8,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): -
C.A.CJ'--
O I. as owner o1 the property, or my employees with wages.as their sole compensation, will do the work, and the -:
❑ As owner -builder, I will -not employ anyone to do work which would require a permit from theDivisionof
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 work from that division..
Law does not apply to an owner of property who builds, or improves thereon; and who does such work himself or
I • . ' - . v . , -
'through his own employees, provided that such improvements are not intended or offered for sale. If, however; the
17 Division of Industrial Safety Permit No.
building orimprovemntissold within one year ofcompletion, the owner -builder will have the burden of proving that.
Date Applicant, '
he did not build or.improve for the•purpose of sale.). ', -
.'•.r'.y ; CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
❑ I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec:
of the work forwhich 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.
ZONE ORO •.:• •
Contractor's License Law.). . ,
Lender's Address
❑ 1 am exempt under.Sec.. ; . B. 8 P.C. (Attached Certificate).
.1certify that I have read this application and state that the above information is correct. ) agree to complywith 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 property for inspection purposes..
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a
- certificate of Workers` Compensation Insurance ; or a certified copy thereof (Seo 3800. Labi,C.). • ,
Signature of Applicant or Agent Date '
Policy No. Company
�. - • - .- • - .. _
CERTIFICATE COMPLIANCE'AND'AUTHORIZATION-0F. ENTRY: I nertify1 have read this application and state that
Certified copy is hereby furnished. k
the information given is correct..l agree to comply with all state -laws and county ordinances relating.to buidling ,
Certified copy is.liled with the City Building Inspection Depa tment of City Department.
construction, and authorize a representative of the City of La Ouinta Department of Building and Safety.to enter
-upon
' �-- U - `1` • --�,�`
Date Applicant,
- - the property, or I have applied for.this permit for'the purpose of making inspections:.:
`. /� r r 1
1 ----^`_'_
T
•. Signrepoff Applicant or Agent ! _ /Date
Print Applicant/Agent Name
APPLICANT NAME (L, F. MI)
B. Munroe
ADDRESS- -
P.O., BOX 1100
CITY/COMMUNITY/STATE/ZIP -
La Qmntat
JOB SITE ADDRESS/SPACE - - -
54-295 Obramn
CITY/COMMUNITY/STATE/ZIP •• • ; I
La Qu inata,. CA 92253
BOK -
77
PAGPRC,
241
0 4
C'
• •
TWN .,,
RNG
SE
.S'
TRACT' LOT.
MOD
SB
...
TRACT NAME.
OWNER NAME (L. F. I) 1•a7.�n • - .,
L�a7J
CONTRACTOR -FIRM NAME
Pir4k .i'n'hncnn (Inns riv+i
ADDRESS -- ,
54-7A0 Atypnicla Rnmirpm
CITY/COMMUNITY/STATE/ZIP
is Quinta, 'CA '92253'
PHONE*
LICNCO
-
ARC/ENG FIRM NAME -
ADDRESS
CITY/COMMUNITY/STATE/ZIP • - -• . 1 -
-PHONE •
Plumbing Feet
LICNC- •
,.
USE OF PERMIT
Sincrle-family dwelling
BL
ZON
FSB
SSB.
SSB'_
- RSB
PD. 7-11 84
OFC
941.67
TOTAL
FEE
ZONE ORO •.:• •
LOT SZ
a
END
•SIDE
APPL/PRMT -
DATE
7-24-84
S.F.D.
Permit to mnstrr `t-
1592 sar
.- of
Sina],e-fermi lv e%3PI l irus anA Al
cn fi-
porch and 430 sq. ft. of garageas
per approved pian. .
mech. Fee
22.00
Plan Cis.' Fee
244.40
Const. Fee
376,00'
Elect. Feet-
43.13 '
Shit Fee
5.64
Plumbing Feet
50.50
Prop. Devel. ' Fee
450.00
L,"1.67
��
(250.00)
PD. 7-11 84
?.
941.67
TOTAL
FEE
r
+ y VALUATION 80,628.80
BLDG. DEPT.
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
8
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
S
7-/
39
Appl. Clearance
7
Framing
%� ,j
,
40
1 Fire Damper
8
Vents
41
Smoke Detection Device
9
Garage Fire Wall
42
Commercial Hood
10
Fireplace P.L.
❑
43
Final
10A
Fireplace T.O.
❑
NON ADDITIONAL INFORMATION
/
ttt `i%/%� �G ��
f
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick Value
7A Walls (Batts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING APP OVALS
15 Ground Plumb hAl
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
PSL
STREET NAME
P)
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
NOTE 0kj
Itith proper validation
this form constitutes an CITY OF LA QUINTA
encroachment permit
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
For the construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewers, water mains
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
�Subdivision Improvement Permit— Class III
DATE:__ Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION —�� ays fadk16E6roR/
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION
DESCRIPTION OF CONSTRUCTION A0111,62V24Y 414100AZ
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WhLL BEGIN
-- .n ,.
Sketch (attach construction plans if appropriate)
o? Za INCHES AF I'I C•
APPROXIMATE TIME OF COMPLETION T��y
ESTIMATED CONSTRUCTION?COST $
(Including removal of all obstruction, materials, and debris, backfilling, com-
k
paction and placing permanent resurfacing and/or replacing improvements) _
In consideration of the granting of this permit, the applicant hereby agrees to:
Indemnify, defend and save the City, its authorized agents, officers, representatives and employees, harmless from and against any and all
penalties, liabilities or loss resulting from claims or court action and arising out of any accident, loss or damage to persons or property
happening or occurring as a proximate result of any work undertaken under the permit granted pursuant to this application.
Notify the Administrative Authority at least twenty-four (24) hours in advance of the time when work will be started.
Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules and regulations of the City of
La Quinta and to pay for any additional replacement necessary as the result of this work.
N
X X;
Signature of Applic Ap. or Agent
3 - 744V �i4il�►�re E 2
Name of Applicant. (please print) Business Address Telephone No.
J%fMO
Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's License No.
City Business License No.
Applicant's Insurance Company Policy Number
r
FEES: Subdivision Improvement Permit — Class I I I G
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costsATC-
1j�Il
Minor Improvement Permit —Class IV: See attached schedu��
Inspection Fee $
Permit Fee F too. 0 O
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
$ 0, 0 0
Received by Date
Recorded by
\N\�WAV PERMIT VALIDATION
d4RMIT NO. 02
DATE APPROVED aG
EXPIRATION DATE
DATE ISSUED `1-30 3L)
By 'T
Administrative Authority
TELEPHONE: (619) 564-2246