BLCK (0114)52470 Avenida Madero
0114
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APPLICANT NAME (L.M,I
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PEflMIT RPPLICAT
ON
City of
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La'Duinta t ,' •r f, .., •'`
Department of Building and Safety
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.
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LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under Chapter 9
+ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE:,This section need not be completed if
is for hundred less.
provisions of
(commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force
the permit one (5100) o, I certify that in the performance of the work for which this permit is
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. -
^' DateApplicant
Date Contractor +' '
NOTICE TO APPLICANT: If, after making this Certificate of 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, you must forthwith comply with such provisions or this permit shall '
,
following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit lob',..
o • 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:
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law
"' 01 hereby certify that no excavation five (5) or more feet in depth into which a person is re'quired to descend. will be
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) orthat he is exempt .•
therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or
subjects the applicant to a civil penally of not more than five hundred dollars ($500.): - '"
C? I as my with '
demolition or dismantling thereof, will be more than thirty-six (36) feel high. (Chap 3.2, Grp 2, Art 2. Sec 341, Title 8.
C.A.C.) '
owner of the property, or employees wages as their sole compensation, will do the work, and the ,
structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License
0 As owner -builder, I will not employ anyone to do work which would require a permit from the Division of
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 '
USE OF PERMIT ' _
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through his own employees, provided that such improvements are not intended or offered for sale. If, however, the
0 Division of Industrial Safety Permit No.
building orimprovemniissold 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.).
SSB
0 I, as owner of the properly, am exculsively contracting with licensed contractors to construct the project (Sed.
CONSTRUCTION•LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
of the work for 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 .
OfC•
,SIDE
builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the
Lender's Name
Contractor's License Law.).
Lender's Address
0 1 am exempt under Sec.
P r D: 8 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
laws
Date • OwnS/er / i . >d rs%
/ N
WORKERS' COMPENSATION DECLARATION: I hereby
city and county ordinances and state relating to building construction, and hereby authorize representatives
of this county to enter upon the above-mentioned property for inspection purposes.
affirm,that I have certificate of consent to self -insure, or a
cenificale of Workers' Compensation Insurance . or a certified copythereof (Sec. 3800. Lab. C.).
Policy No. Company
Signature of Applicant or Agent z Date
O Certified copy is hereby furnished.
r CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling ,
0 Certified copy is filed with the City Building Inspection Department or City Department.
construction, and authorize a representative of the City of La Ouinta Department of Building and Safety to enter
Date Applicant
upon the propertjfolr which.) have applied for this permit for,the purpose of making inspections. ' -
,!.am •,p- -
;
{ "-'e.knaturerof'Applicant or Agent - Date '
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APPLICANT NAME (L.M,I
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ADDRESS
p
76 Ave,
CITY/COMMUNITY/STATE/ZIP p AA
JOB SITE ADDRESS/SPACE
CITY/COMMUNITY/STATE/ZIP
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6010 ?AG, PRC /
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TRACT NAME
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE a
LICNC M
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ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE M -
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USE OF PERMIT ' _
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Arrow Printing 250/1-83,
White: Finance
Print Applicant/Agent Name
APRVPRMT t N 0114 4>71 An ./.f 8/
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Canary: Assessor Pink: Applicant -Tag: Bldg. Dept.
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
fireplace T.O.
❑
OP'N
NO.
ADDITIONAL INFORMATION
-
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