BLCK (001350)54100 Avenida Martinez
001350
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.
ADDRESS -
54-100 Avenida M
" 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. fess,l certify that in the performance of the work for which this 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 employany person inany manner so as to become subject to the Workers'CompensationLaws of,
and effect.
California.
License Class Lic. Number
Date Applicant
-- 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 dor 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 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
01 hereby certify that no excavation five (5) or more feet in depth into which a 06rson 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
demolition or dismantling thereof, will be more than thirty-six (36) feet high: (Chap 3.2, Grp 2, Art 2, Sec341. Title8,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
C.A.C.)
O I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the
O As owner-builde'r, 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
PHONE I
through his own employees, provided that such improvements are not intended or offered:for sale. If. however, the
O 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.).
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 thispermit 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
ASS
Contractor's License Law.).
Lender's Address
O 1 am exempt under Sec. ,[B,.wB cP.CCr(Attached Certificate).
i / % ` '
,. ,.. I certify thaLl have read this application and state that the above information is co(rect. I agree to comply with -all
4 city and county ordinances and state laws relating to building construction, and hereby
Date Owner / • _ c %(tel
--
WORKERS' COMPENSATION DECLARATION: I hereby affirm"that I have a certificete oof consent to self•insure, ora
authorize representatives
of this county to enter upon the above-mentioned property for inspection purposes.
certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. C.)._'
--END
, Signature of Applicant or -Agent Date
Policy No. Company
Ci ERTIFICATE OF COMPLIANCE AND AUTHORIZATIOWOF ENTRY: I certify I have read this application and state that
O Certified copy is hereby furnished:
the information given incorrect. I agree to comply with all state laws and county,ordinances relating,to buidling
' O 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 property for which I have applied for this permit for the purpose of making inspections.
APPLICANT NAME (L. F. MI) Dick.
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ADDRESS -
54-100 Avenida M
CITY/COMMUNITY/STATE/ZIP
La Quinta, CA 92253
JOB SITE ADORESS/SPACE
CITY/COMMUNITY/STATE/ZIP
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OWNER NAME (L. F. MI) _ -- ^,,, '
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CONTRACTOR -FIRM NAME -,
amlicant
ADDRESS
above
CITY/COMMUNITY/STATE/ZIP - -
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PHONE .
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ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE I
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--END
SIDE
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMT
DATE
4-24-85 MW.
Permit to build 75
lin. ft. of 6 ft.
high block, brick and iron fmoe as
per approved pLans.
Plan (heck
20.15
Permit Fee
31.00
SMI Fee
.50
TOTAL
FEE •
51.65
A0.805
BLDG.DEPT.
4 24
VALUATION 1,875.00
NO.
OPERATION DATE INSPECTOR
NO.
OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
2a ;0:—,
34
Plenums & Ducts
2A
Slab Grade
35
Furnace Compart.
3
Steel
36
Inlets & Outlets
4
Grout Blocks
37
Combustion Air
5
Bond Beams
(J
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.
❑
NON
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/I
'
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
.29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final