RER (0484)PERMIT APPLICATION
— City
of La Ouinta a
Department of Building and Safety
This permit becomes void it -work not commenced within 180 days from dale
of issuance,.OR, if.work has been suspended or abandoned fora•period of 180 days. -
.'
PAG .
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: -.This section need not be completed it
' LICENSED CONTRACTORS DECLARATION: I hereby affirm that' I 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 of the Business and Professions Code, and my license is in full force
„ issued, l shall not employ any'person.inany 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 -Certificate of Exemption, you should become subject to.the Workers' .�
OWNER -BUILDER DECLARATION: � l 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 .�
be deemed, revoked.
following reason (Sec. 7031.5•. Business, and Professions Code: Any city or county which requires a permit to
TRACT NAME
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 si.9ned.statement that he is licensed pursuant to theprovisions of the Contractor's License Law
'0' 1 hereby certify that no excavation five,(5l or more feet 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) orthat 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: be more than thirty-six•(36) feet high. (Chap 3.2,.Grp 2, Art,2; Sec341. Title 8, a
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
C.A.C.)- �.ve.:'•
O I, as owner of the property, or my employees with wages as their sole compensation, will do the work; and.the
OFAs 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.
• . ' --' v
through his own employees. provided that such improvements are not intended or -offered for sale. It, however, the
O Division of Industrial Safety Permit No.
building orimprovernnt is sold within oneyear of;ompletion, the owner -,builder will havethe.burden of.provingthat
Date Applicant
he did not build or improve for the purpose of sale.).
'CONSTRUCTION LENDING AGENCY: 1 hereby affirm that there is a construction lending agency for the performance
O I, as owner of the property, am excutsively 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
.,
Contractor's License Law.).. _
Lender's Address
O 1 am exempt u der Sec '• � ^� ^.,. B. 8 P.C..(Attached Certificate):
;;I certify that I haveseaA this application and state that the above information is correcUl agreeto comply with all
✓Date -'— Owner //1 J1�+ o ��' / �✓1- d1
city and county ordinances and state laws relating to build ing.construction, and hereby authorize representatives
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to'self-insure,'or a
of this coUhty to enter upon the above -'mentioned property for inspection purposes.
certificate of Workers' Compensation Insurance -or. a certified copy thereof (Sec: 3800. -Lab. C) V,
'Date.
•Sigeature
of Applicant or Agent
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify l have read Misapplication and state that .
O Certified copy is hereby furnished. ..
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 Department or City Department."
construction, and authorize a'representative of the City of La Ouinta Department of Building and Safety to enter
v upon the property.for which I have applied for this.permit for the purpose of making inspections..
Date Applicant
_ 1
Signature of Applicant or Agent Date
Em p
APPLICANT NAME (L: F. MI)
ADDRESS
:29 3 1? r& 2x_)
CITY/COMMUNITY/STATE/ZIP J 7
JOB SITE ADDRESS/SPACE ��/ - •'
CITY/COMMUNITY/STATE/ZIP /
14 6) /z /
BOK
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PRC .,
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7 .7
TWN
RNG
SE •-
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TRACT ,
_ LOT
!^ TOTAL
•' FEE •
p: e./ / r
MOO
SB•
TRACT NAME
OWNER NAME (L. F. MI) - �j �• %% J ,
CONTRACTOR -FIRM NAME -
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE . 7
LICNC •
..
ARC/ENG FIRM NAME
ADDRESS - -
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC .
USE OF PERMIT '
BL
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FSB,
'SSB
t SSB
RSB
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ZONE ORD .
LOT SZ'
END
SIDE'.
Print Applicant/Agent Name
APPLNRGMT �• � � � � / _ATE
Rita
• ,(��D/NE P�Ri�ir /6%.00•
v1;79/N
7 .7
�Q��tJ/c�wA� QF rOCRAF 4
oJ AM 6 1983
City•®f La*Quinta
!^ TOTAL
•' FEE •
p: e./ / r
VALUATION gy6,�o
BLDG. DEPT.
NO.
OPERATION DATE
INSPECTOR
NO. OPERATION DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
233
Ventilation System
2
Ftgs & Frms
34 Plenums & Ducts
2A
SFab—GFacfe -C (R. -'Q1S-T- �
�
35 Furnace Compart.
3
Steel
36 Inlets & Outlets
4
Grout Blocks
37 Combustion Air
5
Bond Beams
38 Compressor
6
Roof Deck
j /3
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.
❑
NPON ADDITIONAL INFORMATION
JJ (\
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Ole
SEWAGE SYSTEM SIZE & LOCATION .
11 Exterior Lath % e
12 Internal Lath(.�/
12A Drywall
13 Finish Grade
INSULATION Thick Value fl -oak
7A Walls (Batts)
126 Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING A ROVALS
15 Ground Plumb /
16 Water Piping
17 Rough Plumb 3Z9 �7-l•
18 Vents
19 Sewage Disposal
20 Sewer
21 Water Heater s
22 Water Softener
23 Water Service
24 Gas Test 3 t9
25 Final
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
PSL
STREET NAME
PiI
26 ' Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
A-