RPL (0629)52380 Avenida Martinez
0629
PERMIT APPLICATION
City of La Ouinta
.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.
ADORE 7 led.
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE:This section need not be completed if
' LICENSED CONTRACTORS DECLARATION:'I hereby affirm that I am licensed und'erprovisions oh 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) o1 Division 3 of the Business and Professions Code`, and my license sin full force
issued:I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws o1
and effect. r; / / .— Uj (
California.
License Clas /---'Cic. Number— /J
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Date Applicant '
Date Contractor J ` - (J
NOTICE TO APPLICANT: 4f, after: making this Certificate of Exemption, you should become subject to the Workers'
OWNER -BUILDER DECLARATION: I hereby, aflirin'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
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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 oltheContra ' ctor'sLicense Law,
••. 01 hereby certify that no excavation five (5) or more f6el 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 in connection 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 -i
demolition or dismantling thereof, will be more than -thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2; Sec341, Title 8.
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
C.A.C.) Y' )W' • '
❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the .
0 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 work himself or
CITY/COMMUNITY/STATE/ZIP -
' 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 orimpr-ovemntissoldwithinone year ofcompletion;theowner-builder will have the burden of proving that ..
Date Applicant"
he did not build.or improve Jor the purpose of sale.).
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CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
O 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 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
SSB
Contractor's License Law.).
Lender's Address
O 1 am exempt under Sec. B: 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
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ot.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 (Sec.'3800: Lab: C.).. .
Signature of Applicant or Agent Date
Policy No. Company
CERTIF.ICATEOF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and statethat
❑/Certified copy is hereby furnished. { /
the information given is correct. I agree to comply+with all state laws and county -ordinances relating to buidling
the City La Ouinta Department Building
Certilied'copy is'Iiled.wityMhe'City Building Inspection^Department'orCity ` Department. f .
construction, and authorize a:representative of of of 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 Applicant
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPLICANT NAM (I., ,, MI)
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CITY/COMyI'WNI`eT AfE/ZIP. /WIA / — ' 2,4
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JOB SITE-A'DDRE PAACEr. . /'Vr'(r- {yw( J• 7 fAl
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AR 7 .• 1984
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TRACT NAME
OWNER NAME (L• F. MI) -
CONTRACTOR -FIRM NAME . • - -
ADDRESS
CITY/COMMUNITY/STATE/ZIP
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PHONE G CJ r✓D/
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yICNC
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ARC/ENG FIRM NAME
ADDRESS '
CITY/COMMUNITY/STATE/ZIP -
PHONE 1
-LICNC II
-
USE OF PERMIT
BL
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FS8
SSB
SSB
RSB
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' ZONE ORD I -
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.END
. SIDE
APPL/PRMT DATE
3 01 -
17 7_0 Leo v5 7•ea67" 6 7 .
f' fi %Gci 'C T 'T ;1 ✓06 /45
14AI4 ' lO,e 41AI % IV 4 -n>
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RECEI
AR 7 .• 1984
TOTAL
FEE
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VALUATION F
7777-3 `/
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
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.
❑
NADDITIONAL INFORMATION
NO.
O.
/
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick 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
pI
STREET NAME
PROPERTY LINE
P/I
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
296, Bonding
30 Fixtures
31 Service
32 Final