GRD (0574)APPLICAN NAM (L. F, MI)
ADDRESS r►"
77
PERMIT APPLICATION
JOB SITE ADDRESS/SPAC3 � Ile
- City of La Ouinta�F r
Department of.Building
and Safety _ t
This permit.becomes void if work not,commenced within 180 days from date of.issuance,.OR, if work has been suspended.or abandoned fora period'ot 180 days. , > :' ' •'
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C
CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATIONINSURANCE: This section..neednotbecomptetedif-:
LICENSED 'CONTRACTORS OECLARATION'r1 hereby, affirm that I amAcensed under.'provisions of Chapter 9 -
Ahe.permit is for.one hundred ($100) o• less..) 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 mannerso asto become subject to the Workers'Compensation Laws of - ,
• and effect.
California.
' License.Class Lic. Number
Date _ Applicant •. f
' ,Date-.. Contractor ..NOTICE•TO APPLICANT: If, after making this Certificate of -Exemption; you should become subject to the Workers' p
-OWNER-BUILDER DECLARATION:.I hereby -affirm that I �am'exempt'from the Contractor:s License. Law'Jtor Me ..
Compensation;provisions of the Labor Code, you must forthwith comply with such provisions orchis permit shall
- .. +
berileemed revokedr 'd
following reason (Sec. 7031 Business and Professions Code: Any city 'or;county.which. requires a permit to
5.
OWNER NAME (L, F. MII
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 '
_0 I hereby certify that no eicav6tion five (5) oemore feet in,depth into Which a person isiequired 16 descend, Will be
;(Chapter 9(commencing with.seclion 7000) of Division 3 of the Business and Professions Code) or thalheisexempt
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 'ordismantlingthereof, will be more'than thirty-six (36)`feet high. (Chap'3.2, Grp 2 Art 2. Sec341,7it1e8;' .4.4
subjects a applicant to a civil penalty of not more than five hundred dollars ($500.):' ,ks-iia'
C.A.C.)''
. as owner,of the properly, or: my employees with wages as their sole compensation, will do the work, and the••
p-As.owlier•builder, Iwill not employ anyone to do work which would require a permit from the Di6ision 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
' through.his own employees: provided that such improvements are not intended or offered for sale. If, however, the c
O Division of Industrial Safety Permit No. w
building orimprovemntissoldwithin one year ofcompletion,the owner -builder will have the burden of p roving that
^ Date Applicant a r
.he did:not build or improve for the purpose of sale.),
CONSTRUCTION LENDING AGENCY:.I hereby affirm that there is'.r a construction lending agencyfor the performance
' O. I; as owner of the property„am exculsivety contracting with licensed contractors to Construct the project (Sec.. ,
of the work for which this permit -is issued (Sec;3097, Civ: -C.). :, r..
• 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
❑ I am exem Inde Sec. �! '— '—�' ' /•. B. IB/�P.CJ. Attached Certificate).'
I certify that Lhave-read this application and state that the above information is correct. Pagree to comply with all
laws building hereby
Date' "� Owner �� = .^' B! �, fi✓-� �”
city and county ordinances and state relating to construction, and authorize representatives -a...•
�{ :/ /v. r� iq
of this county to -enter upon the above-mentioned property for inspection purposes. -
WORKERS' COMPENSATION DECLARATION: i hp eby affirm thatd'have a cerli Icale'of consent to self -insure, ora."
certificate of Workers' Compensation Insurance , or a certified copytherecf (Seo:3800. Lab. C:).:. :
r
Signature of Applicant or -Agent Date
Policy No. Company..
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify l have read this application and state that
0.Certified copy is hereby furnished.I.
the informaliorrgiven is correct. I agree to complywith all state laws and county ordinances relating to buidling ..
-�O Certified copy is filed with City Building Inspection Department or City �' ���� Department.' � . p y of La Ouinta De artmentof Building and Safety to enter '
"' construction; and. authorize a're resentative.of the Cit p g y
the.property.for which I have applied for this permit for the purpose of making inspections.
,Date Applicant :..upon
,
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPLICAN NAM (L. F, MI)
ADDRESS r►"
77
CITY/COMMUNIT /STATE/LIP
JOB SITE ADDRESS/SPAC3 � Ile
CITY 0M0MMUNUNITY/STATE/ZIP
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TWIN .•
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'TRACE b �
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LOT
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MOD
Sei
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TRACT NAME
OWNER NAME (L, F. MII
CONTRACTOR -FIRM NAME r -
ADDRESS - •'
CITY/COMMUNITY/STATE/ZIP ..
PN NE,}i j�
UCNC 11
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ARC/ENGFIFIRM NAMED"
ADDRESS -
CITY/COMMUNITY/STATE/ZIP .. • -
PHONE N
LICNC 4 -
- -
USE OF PERMIT
BL'
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SSB-''
SSB ':
RSB
OFC
ZONE -ORD --:
LOT SZ
.. END'-' ,P1ecSIDE
;�• ` BLDG. DEPT. -
•'TOTAL °�•
FEE
VALUATION .��
NO.
OPERATION DATE
INSPECTOR
NO. OPERATION DATE 7NSPECTOR
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.
❑
OP'N ADDITIONAL INFORMATION
NO.
✓� r
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
PSL P)
"
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final