ELEC (0293)52360 Avenida Madero
0293
APP L C.AsNT` N A(ME (L. K. M -
PERMIT APPLICATION -
. City of La
Ouinta'
Department of Building and Safety
.r '-:.'-.This permit becomes void if work not commenced within 180 days from•date of issuance, OR, it• work has been suspended.or abandoned fora period of 180 days::.. + .
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CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section rieednot be completed if
LICENSED CONTRACTORS -DECLARATION: I herehy .affirm that t: am: licensed under provisions of.Chapter-9 "' ' ` ' `,
' the permit'isfor.one hundred ($100) o„ less: I certify that'in the performance of the work for.whichthis permit,is - •':
'• (commencing with.Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force, •
-issued; I shall not employ any person in any manner so as to become subject to the,Workers'Compensation Laws of'.
and effect.
California.
License Class Lic. Number
Date Applicant
- - Date • =• -'- ' Contractor
NOTICE TO APPLICANT: If, after making this Certificateof.Exemption, you should become subject to the Workers'
' OWNER -BUILDER DECLARATION: I hereby'affirm that I'am exempt from the Contractor's License Law for'the: "..
Compensation. provisions of the Labor Code,.yoamust forthwith comply with such provisions or this permit shall '
'following reason (Sec. 7031.5. Business and Professions Code: Any city orcounty which requires a.permif to ..'.
be deemed revokeA,
' construct, alter, improve, demolish, or repair any.struciure: prior to its issuance, also:requires the applicant for • ...
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION ..
- suqbperrfiit to file a signed.statement that he is licensed pursuant to the provisions of the Contractor's License Law
•`0:1 rebycertifythatnoexcavationfive(5)ormore feet indepthintowhich aperson isrequired todeseend,.willbe-.
' (Chapter 9 (commencing with section 7000) of Division 3 of the Business and Prof essionsCode)orthat he is exempt- .
made in'connection with work authorized by'ihis 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 permitdemolition
or dismantling thereof, will be more thanthirty-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 (5500.). :...rs•.... " •..
^ C.A.C.)
® I. as owner of the property. or my employees with wages as their sole compensation, will do the work,'and the ti
p As -owner -builder, I will not employ anyone to-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 persomhas'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
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?. through his own employees; provided that such improvements are not intended or offered for safe. It, however, Iher-. `
'0 Division ot:lndustrial Safety Permit No.
• building or improverrmt is sold within one year of completion. the owner -builder will have the burden of proving that. :.
Date 'Applicant
.he did not build, or improve for the purpose iofsale.).
'I,
'CONSTRUCTION LENDING AGENCY: I'hereby affirm that there is a construction lending agency for the performance •+`
. O as owner. of the property, am exculsivefycontracting with licensed contractors to construct the project (Sec.:,:. -
of the work for which this permit isissued. {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 coritractor(s)licensed pursuant to the '•
Contractor's License Law.).. p 6f .. _
Lender's Address -
0:I am_exempiundd r. ecc. ✓• t' B.,& !(A
P.Cttached Certificate).`
s
I certify that 1 have read this application and state'.thatthe above information is,correct. I agree to comply with all
" Da(e'r "J j - " ` "Owner / %I i_ '
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
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-of this county to enter upon the above-mentioned'property for inspection purposesx
' WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or.a-
' certificate of Workers' Cofhpensation Insurance',. or a.certified copy thereof fSec. 3800. Lab. C.).": -'
- ,
Signature of Applicant or Agent Daie
P.olicy:No. Company., •-'r
CERTIFICATEOF COMPLIANCE ANDAUTHORIZATION'OF ENTRY: I certify lhave read this application and state that
• C1Certified copy is hereby..furnished. ; =rq -
the information given is correct. I agree to comply with -all state laws and county ordinances relating to buidling
" O Certified copy is filed with.the City Building Inspection bepartment or City Department: • . `}
construction, and authorize a representative of the City of La Ouinta Department of Building and Safety to enter
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upon the property for which I have applied for this permit for the purpose of making inspections.. .
Date plicant
.. , s
'
Signature of Applicant or Agent Date
-
Print Applicant/Agent Name
APP L C.AsNT` N A(ME (L. K. M -
CITY/COMMUNITY/STATE/ZIP
J08 SI E AOORES SSP/PACCE E
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CITY/ MUNITY/STATE/ZIP
80K
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TRACT NAME
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME '
ADDRESS - -
CITY/COMMUNITY/STATE/ZIP
PHONE Ir
LICNC 0
ARC/ENG FIRM NAME ,
ADDRESS
CITY/COMMUNITY/STATE/ZIP . •""
PHONE II
LIC NC •
- - P • •
USE OF PERMITS -
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END
SIDE.
APPL/PRMT RA .U - •- l irr //'IG..
moo'
00":0 Wr ' A _sy 4
A
AUG 2 5 1983.
City of La'Quinta `
I UJ
TOTAL
w rs VALUATION Q
BLDG. DEPT.
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
3.5 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
fireplace T.O.
❑
NADDITIONAL INFORMATION
O.
NO. '
/-2- 7/ 1
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A, Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
12B 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/1
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire.
29B Bonding
30 Fixtures
31 Service
32. Final