0356 (GRD)PERMIT APPLICATION �d •� ��' �`��
City of La Ouinta
Department of Building and Safety
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.
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force
and effect.
License Class
Lic. Number
i .Date Contractor _
` OWNER -BUILDER DECLARATION: I hereby affirm" that I am exempt from the Contractor's License Law for the
following reason (Sec. 7031.5. Business and Profession$ Code: Any city or county which requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
such permit to file a signed statement that he is licensed pu rsuant to the provisions of the Contractor's License Law.
�.
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) or that heis exempt
therefrom and the basis for the alleged exemption. Any violation. of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
❑ 1, as owner of the property, or myemployees 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
Law does not apply to an owner of property who builds.Ar 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
building or i mprovemni is sold within one year of completion, the owner -builder will have the burden of proving that
he did not build or improve for the purpose of sale.)., y
❑ I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec.
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
Contractor's License Law.).
0am exempt under Sec: Bir&y P.C. (Attached Certificate).
(/pate 1i%.WJ "I Owner
I fEdi bins
WORKERS'S' COMPENSATION DECLARATION: I hereby affirm that��Fhave a certificate -of consent to self -insure or a
certificate of Workers' Compensation Insurance , or a certified'eopy thereof (Sec. 3800. Lab. C.). V
Policy, No. Company
❑ Certified copy is,hereby furnished.
O Certified copy is filed with the City Building Inspection Department or City
Date Applicant
Department.
APPLICANT NAME (L, F, M11 ' ��F
.,
CITY/COMMUNITY/STATE/ZIP
JOB SITE ADDRESS/SPACE
CITY/COMMUNITY/STATE/ZIP
LA Q al"7A .4'A'
BOK
PAG
PRC
C
TWN
RNG
SE
S
TRACT
LOT
TOTAL
FEE •
a ��
MOD
SB
TRACT NAME
OWNER NAME (L. F. MI(
CONTRACTOR -FIRM NAME
AW14
ADDRESS
CITY/COMMUNITY/STATE/ZIP "
PHONE I
LICNC •
ARC/ENG FIRM NAME -
ADDRESS
CITY/COMMUNITY/STATE/ZIP "
PHONE N
LICNC •
USE OF PERMIT
BL
I
I ZON
FSB
SSB
SSB
RSB
OFC
ZONE ORD • ,.
LOT SZ
END
SIDE
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
the permit is for. one hundred ($100) o, less. I certify that in the performance of the work for which this permit is
issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of
California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of -Exemption, you should become subject to the Workers' •
Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
'O 1 heieby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be
made in connection with work authorized by this permit, and'that no building structure, scaffolding, falsework, or
demolition or dismantling thereof, will be more than4hirty-six (36) feet high. (Chap 3.2, Grp 2, AA 2; Sec341, Title 8,
C.A.C.)
O As'owner-builder, I will not'employ anyone to do work which would require a permit from the Division of
Industrial Safety, as noted•above, unless such person has a permit to do such work from that division.
❑ Division of Industrial Safety Permit No.
Date Applicant
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.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the above information is correct. I agree to comply with all
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.
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 Safely to enter
upon the property for which I have applied for this permit for the purpose of making inspections.
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPL/PRMT WISH DATE �1�83
Tv 6'ell 0e J ,o�•�
,QPP,Pov,�'o �LA�
NOV 6 1963
City of La Quinta
TOTAL
FEE •
a ��
VALUATION
J
NO.
OPERATION DATE
INSPECTOR
NO. OPERATION. DATE INSPECTOR
BUILDINGAPPROVALS
MECHANICAL APPROVALS
1•
Set'Back
33 .-Ventilation System
2
Ftgs & Frms
34 Plenums & Ducts
2A
Slab Grade '
35 Furnace Compart.
3
Steel
36 Irifets"& 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.,
0
43 Final "
16A
Fireplace T.O. ❑ :
NO ADDITIONAL INFORMATION
V i"
_ ..
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12- Internal Lath,��
12ADrywall
t3 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
^
P/L P/L
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 .. Wiring
29A Grounding Wire
29B" Bonding
30 Fixtures
31 Service
32 Final