BLDG (000970).;�. IFAS '{, •y, 'Y '- X>>1;G•���i-/
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' ��!"'.•�r�PERMITAPPLICRTIONI!�•','rj�-�3>'•
°� ��S -' .
' City of
La Ouinta-.'.'a' ' r
j Department of Building
and Safety
- This permit becomes void if work not commenced within 180 days from date of
issuance, OR;'it,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 ..
LICENSED CONTRACTORS DECLARATION; I hereby- affirm thal'I am licensed .under, provisions of Chapter 9 '
'.the.permil 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, I shall not employ any person inany manner so as to become subject to the Workers'CompensationLaws o1
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' •,
n: ••
'OWNER -BUILDER DECLARATIO(V:.I hereby affirm that I am.exempt from the Contracto'r's License Law lorthe '
Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall „t
,
• 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:
suchpermittofileasignedstatementthathe'islicensedpursuanttotheprovisionsoftheContractor'sLicenseLaw: •.
-01 hereby certify that no excavation five (5) 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 nobuilding' structure, scaffolding, falsework, or
• therefrom.and the basis for the alleged exemption. Any violation of Section,7031.5 by any,appli6ant for a permit ,
demolition or dismantling thereof, will be more than thirty-six (38) feet high. (Chap 3.2; Grp 2 Art 2, Sec341, TitleB, :%rg
subjects the applicant'to a civil penalty of not more than five hundred dollars ($500.):
0 1, as owner otthe property, ormy employees with wages.as their sole compensation, will do the work; and the
`C.A.C.)
:. �l As owner -Wilder; Twill not employ anyone to do work'which wouldrequire a permit from the Division of
.structure is not intended or offered for sale (Sec. 7044; Business and Professions Code: The.Contractor's License .•
Indusliial 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
,,.ir
industrial
through his own employees• provided that such improvements are not intended or offered for sale. If, however, the ^
building improvemnt is
0 Di*ion of Satety Permit No.
�y�1•'+r-�%�
or soldwithin one year of completion. the ow.neribuilder will have the burden of proving th - at
Date'• Applicant �-''��•��`•P-�=- -^.%
he did not build or improve for the purpose of sale.),
9 1 as owner of the am exculsively contracting with licensed contractors to construct the
CONSTRUCTION LENDING AGENCY:I hereby affirm that there Is a construction lending agencyforthe performance.
properly; project (Secof
/044; Business and Professions Code: The Contractor's License Law does not apply to an.owner of property who'
the work for which this permit. is issued. (Sec. 3097, Civ. C.).. .. ... ..
• 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 1 am exempt under Sec. B. & P.C. (Attached.Ceitificate); . •
I certify that I have read this application and state that the above information,is correct. I agree to comply with all -
+ t' ` ;1; _ < - .; ..�
Date '' °' �Ownei ' • �"-�' ' ^ .r
cit and count 0 9 Y D
Y y ordinances and state laws relatin ,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, ora -
certificate of Workers' Compensation Insurance , ora certified copy thereof (Sec. 3800. Lab. C.).. ;`
Signature of Applicant or'Agent Date
Policy No: Company a s
CERTIFICATE OF COMPLIANCE -AND -AUTHORIZATION OF ENTRY: I certify I have read this application and'state that
.0 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:Cerfified 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,.. ,
the property for have applied forthlS•pe}mit for inspections.
- _ .. ., -
Date M Plicant �
upon which') the purpose of making .
`/.�%•��-e�l:.'�G-
Signature of Applicant or Agent Date -
APPLICANT NAME (L. F. �MI) _
i ;,,` �J l:r � ti i. l �'�• �Y r 1 / •y%_.. )'ter .�. ;. /
ADDRESS
CITY/COMMUNITY/STATE/ZIP ,
JOB SITE ADDRESS/SPACE..
Zi'4
CITY/COMMUNITY/STATE/ZIP
BOK
PAG
PRC
C
.,.
TNM
RNG .,
SE
S'
TRACT
LOT
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MOD
SB.
-
TRACT NAME.
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME : ..
ADDRESS
CITY/COMMUNITY/STATE/ZIP
. r
PHONE s
:s. TOTAL:
FEE
LICNC 0
,
ARC/ENG FIRM NAME •. - -
ADDRESS .. -.
CITY/COMMUNITY/STATE/ZIP - ^
PHONE II •.
LICNCA
..
USE OF PERMIT
BL
ZON
,• FSB
SSB
SSB,
RSB
OFC,--
; ZONE ORD M ; :",
-LO T.SZ
• END
SIDE '
Print Applicant/Agent Name
..'x ;".
APPL/PRMT � � � . v DATE '/
G
42
`116-,1/
1_,'_A1CZ7_
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r y
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'
A41 P
+
:s. TOTAL:
FEE
_. VALUATION
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.
❑
N0.
ADDITIONAL INFORMATION
-71W
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12
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
PSL P/I
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
296 Bonding
30 Fixtures
31 Service
32 Final