PAT (0138).. ^ PERMIT APPLICATION
a. City of
"t
La Ouinta
• 1. Department of Building
and Safety'
4• _ _
PAG
This permit becomes void if work not commenced within 180 days from date of
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issuance, OR, if work has been suspended or abandoned for a period of 180 days.
'
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE This section need not be completed if y
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 •
the permit is for one hundred (S100) o, less. I certify that in the performance of the work for which this permit is
(commencing with Section 7000) of Division Sof the Business and Professions Code, and my license is in full force
issued, I shall not employ any person inany mannerso asto become subject to the Workers' Compensation Laws of
' and effect. '
'California.'
k 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 for the
�•-Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall
be deemed N
,following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to
revoked.
- , I -
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for ,
, DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: r
�such permit tofile asigned statement that heislicensed pursuanttothe provisions ofthe Contractor's License Law
❑ IherebycertilythatnoexcavationfiJe(5)ormorefeetindepthintowhichapersonisrequiredtodescerid.willbe
(Chapter 9 (commencing with sectioned ex of Division 3 of the Business and Professions7031.5byCode) or that he is exempt
therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a•permit - ,
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made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or �.
demolition or dismantling thereof,. will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2:Sec 341, Title 8.
- subjec s the applicant to a civil penalty of not more than live hundred dollars (5500.): - •.
C.A.C.) -
as owner of the property, or my employees with 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
❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of
Law does not apply to an owner of property who builds, or improves thereon, and who does such work himself or
Industrial Safety,, as noted above, unless such person has a permit to do such work from that division. '
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 orimprovemniissoldwithinone 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.).
FSB
0 I, as owner of the property, am excufsively contracting with licensed contractors to construct the project (Sec.
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
— .
• 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 I am exempt under Secq / B. 8 P,C4Attached Certificate).,
Iy/ t (J . �'S:%�:•
I certify that I have read this application and state that the above information is correct. I agree to comply with all
Date Y'—�'�' Owner Q�l< i S
' /'/ � t
W RKERS' COMPENSATION DECLARATION: I hefeby a firm that I have a certificate of consent to self -insure, or a
city and county ordinances and state laws relating to building construction, and hereby authorize representatives f..
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.).
Policy No. - Company
0 Certified copy is hereby furnished.
0 Certified copy is filed with the City Building Inspection Department or City Department.
w
Date Applicant
APPLICANTI NAME (Lr, F. MI)
ADDRESS•• .. !j.+j y� ^y ,
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_TCITY/CO(hM�MUNITY/STATE/ZIP
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JOB SITE ADDRESS/SPACE
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CITY/COMMUNITY/STATE/ZIP
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TRACT NAME -
OWNER NAME L. F. MI) t
C�,��N fL,E U
CONTRACTOR -FIRM NAME I '
ADDRESS ,
CITY/COMMUNITY/STATE/ZIP
PHONE a
LICNC N-
-
ARC/ENG FIRM NAME
ADDRESS - -
CITY/COMMUNITY/STATE/ZIP
PHONE a
LICNC a
USE OF PERMIT - -
81.
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END
SIDE
Arrow Printing 250/1-83'
White: Finance
Signature of Applicant or Agent Date
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
construction, and authorize a representative of the City of La Ouinta Department of Building and Safety to enter
upon the property for which l have applied for this permit for the purpose of making inspections.
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMT
`!� i � eb h'l� � TMJ '�$1-.•� .,7 ile�ti"�,s�•w �� '
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- ` F TOTAL
.FEE.-'
Canary: Assessor Pink: A licant. 4Ta 'BI`Dept,�VALUATION I .
PP 9� dg. •
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.
❑
NPON ADDITIONAL INFORMATION
w/o ,�(
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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)
126 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
'
pI 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