BLCK (0664)53854 Avenida Madero
0664
PERMIT APPLICATION
City of La Ouinta o
Department of Building and Safety
This permit becomes void it work not commenced within 180 days from date of issuance. OR, if work has been suspended or abandoned for a period of' -180 days
APPLICANT NAME (L• F, MI•j ,,. ` -,CLD-IT 7
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
-LICENSED CONTRACTORS DECLARATION: I'hereby affirm that 1, am licensed',under provisions of Chapter 9 . •
the permit is for.one hundred ($100) o,.less. I certify that in the performance of the work for which this permit is
' (commencing with Section 7000):of Division 3 o1 the Business and Profe,ssios Code, and m Iicep a is in full force
and effect. r 3 7,
issued, I shall not employ.anyperson inany mannerso as to become subject to the Workers' Compensation Laws of,
California.
License lass L•ic. NumbCef,
--
_Date Applicant
Dale - - - Contractor • ' " • .
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to;the.Workers, •
,
OWNER -BUILDER DECLARATION: 1 hereby affirm that I am exempt ffom.the Contractor's License Law for the -
Compensation provisions of the Labor Code, you.must forthwith comply with such provisions or thispermit shall, ^
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:
such -permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law. ••
0 1 hereby certify that no exca vation five (5) or more feet in depth into which a person is required to descend, w ill be
(Chapter 9 (commencing with section 7000) of Division.3 of,the Business and Professions Code)or that he is exempt,
made in connection with work authorized by this permit, and that no building structure, scaffolding, talsework, or
therefrom and the basis for. the alleged exemption. Any violation of Section 7001,5 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:2fSec341, Title 8,
' subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
C.A.C.) I ` '•
❑ I, as owner of the property, or my employees, with wages as their sole compensation, will do the work: and the.
O.'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 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 workhimself or
through his own employees. provided that such improvements are not intended oroffered for.sale. If, however, the -
O. Division of Industrial Safety Permit No.
building orimprovemntissold with inone year ofcompletion, the owner-builderwillhave theburdenof, provingthat .
Date Applicant
he did not build or improve for the purpose of sale.). :°:•... •.
'
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 for which this permit is issued (Sec.. 3097,.Civ:`C.).
7044, Business and Professions Cade: The Contractor's License. Law does not apply to an owner of property who .
Lender's Name' r
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
O 1 am exempt under Seca .0. 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
' 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
LOT SZ ,
certificate of Workers' Compensation Insurance , or a certified copythereof'(Sec. 3800. Lab. Q. •
Si nature of Applicant or Agent Date
9 D 9
Pofic ,No. Company / / 7 -
ertified
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
copy is hereby furnished. -; . (• (/
'
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
'representative
'1r/
Certified'Ao y:is filed 'the City Building Inspection Departmenl;o: City Department.
construction; and, authorize a're of the Cit of La Ouinta De
D y Department of Building and Safety to enter
•^ L "J ( y c. '
Date Applicant .Ay / 7 / .
upon the property for which I have applied for this permit for the purpose of making inspections:
.
--_ .•
ll / 'ry
Signature of Applicant or Agent Date
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Print Applicant/Agent Name
APPLICANT NAME (L• F, MI•j ,,. ` -,CLD-IT 7
ADDRESS 1
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CITYrfCbMMUUN1 /STTATE ZIP(_,,gW ^r
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ARC/ENG FIRM NAME -
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USE OF PERMIT
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END
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VALUATION
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VALUATION
BLDG. DEPT.
NO.
OPERATION 1 DATE
INSPECTOR
NO.
OPERATION I 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.
❑
NPON
ADDITIONAL INFORMATION
1-7Z12A
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
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
PSL P)
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final