BLDG (001027)PERMIT APPLICATION
City of
La Ouinta
Department of Building
and Safety
1
.PAG-
1 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.
.1
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed it
LICENSED CONTRACTORS DECLARATION: Ihereby 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, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of
and effect.
_
7 ���
California.
License Class 17 / Lic. Number 1
Date Applicant
Date �+ T "'" .;�'c/ Contractor' c.i C 7. .+� -/� o� s• �'_
NOTICE TO APPLICANT: If, after making -this Certificate ot:Exemption, you should become subject to the Workers' '
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It
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
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 irilo which a person 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 of dismantling thereof, will bemote than -thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec 341, Title 8,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
C.A.C.) Z'1 "
O 1, as owner of the property, or my employees with wages as their.sole,compensation, will do the work, and the
O As 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
ZON
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 orimprovemniis'soldwitbihoneyearofcompletion,theowner-builderwillhavetheburdenofprovingthat.
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 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
Contraclor's License Law.).
Lender's Address
O 1 am exempt under Sec. B.1 P.C. (Attached Certificate).
I certify that I have read this application and state that the above information is correct: I agree to comply with all
Date Owner
city and county ordinances and state laws relating 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 1 have a certificate of consent to self -insure, or a
certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800.•Lab. C.).
Policy No. Company.
O Certified copy is hereby furnished.
. O Certified copy is filed with the City Building Inspection Department or City Department.
Date Applicant
APPLICANT NAME (L F, MI)
Qlstan Roofing Ompany
'ADDRESS
78-550 Darby Rd.
CITY/COMMUNITY/STATE/ZIP
Indio, CA 92201
JOB SITE ADDRESS/SPACE -
52-279 Navarro
CITY/COMMUNITY/STATE/ZIP '
Ia Quinta, CA 92253
BOK
.PAG-
PRC
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PING
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TRACT
LOT
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SB
-
TRACT NAME
OWNER NAME (L. F. MI) - -• -.
Mrs. S<Xarcy
CONTRACTOR -FIRM NAME
applicant
ADDRESS
above
CITY/COMMUNITY/STATE/ZIP �,,,,
ab e
PHONE •
345-3751
LICNC �
274 921
'
ARC/ENG FIRM NAME -'
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE •
LICNC It
USE OF PERMIT
re -roof
BL
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'FSB
SSB
SSB
RSB
OFC '
ZONE ORD N
LOT SZ
END '
SIDE.
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:, t.certify l 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 I have applied forfI is permit for the purpose of making inspections.
K Signature of Appllc9t or Agent Date
Print Applicant /Agent Name
APPL/PRMTDATE
nn1 n,/. 10-26-84 17LXJL?.
Permit to resnom all tile, resheet front
front deck with half inch plywood, install
2 layers RE lb. felt with S tile. on top.
Permit 50.50
SMI F`ee .50
U 14
TOTAL
FEE
X51.00
BLDG. DEPT. VALUATION 4,200.00
NO.
OPERATION DATE
INSPECTOR
NO. OPERATION DATE INSIPECTOR
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.
❑
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
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