0673 (BLCK)PERMIT APPLICATION �. J
„i 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, it work has been suspended or abandoned for a period of 180 days, ' . .,
-ADDRESS C—)
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed it
LICENSED CONTRACTORS DECLARATION: I hereby 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
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'
'OWNER -BUILDER -DECLARATION: I hereby affirm that l am exempt fiom 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 provisionsofthe Contractor's LicenseLaw-:'_i
01 herebycertify that no excavation five (5) or moriffeet in depth intohhich'a perso'n is required to descend, will be '
(Chapter 9(commencing with section 7000) of Division 3 of the Business and Professions Code) or thathe is exempt
made in connection withwork authorized by this permit, and that no building structure, scaffolding, falsework, or.- '
.:therefrom and the basis for the alleged exemptiontAny violation of Section 7031.5 by any applicant for a permit - •
demolition or dismantling thereof, will be more than thirty-six (36) feet high: (Chap3.2. Grp 2, Art 2, Sec 341, Title 8,
subjects the applicant to a civil penalty of notmore than -five hundred dollars ($500.):
C.A.C.)
O I, as owner,of the properly, 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 woik 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
r •q -
througli',his own employees, provided that such improvements are not intended or offered for sale. If, however, the
O Division of,lndustrial Safety Permit No.
building orimprovemntissold within one year ofcompletion, the owner -builder will have the burden of proving that
Date Applicant
• t h ydid 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 10 construct the project (Sec:
. v 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
SSB'
Contractor's License Law.).
Lender's Address
O 1 am exempt under Sec. B. 8 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 buildingconstruction, and hereby authorize representatives
LOT SZ
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, or a, '
END
certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. C.). '-
Signature of Applicant or Agent " Date
Policy No. Company
iw
CERTIFICATE OF COMPLIANCE AND AUTHORIZATI9N OF ENTRY: I certify I have read this application and state that '
O Certified copy is hereby furnished.. +:+
the information givendi correct. I agree to comply with -MI -state laws and county ordinances relating to buidling
•O Certified copy is filed with the City Building Inspection Department or Cfty Department.
`c�onstruction,and authorize a'represeotati a of the City.�0a Ouinta Department of Building and Safety to enter -
'
upon the property°,fo�r which I -have applied for this permit for the purpose of making .ins ectionns,./
Date Applicant
f >, �f _^
Signature of Applicant or Agent Date
D
APPLICANT NAME.(L F MI)
-ADDRESS C—)
CITY/COMMUNITY/STATE/ZIP
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JOI3-SJ1,TF:ADDRSS P CEII /// •'
CI Y/CO MUNINIXY/STATE/ZIP '
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TRACT NAME
OWNER NAME (L. F. MIt
CONTRACTOR -FIRM NAME .
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHO.N/E—•1
LICNC •
Quirita
ARC/ENG FIRM NAME ' '
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE II - -
LICNC •
'
USE OF PERMIT '
BL
1
1 ZON
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SS8
SSB'
RSB
OFC
'ZONE ORD •
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END
SIDE -
Print Applicant/Agent Name
APPL/PRMT K 7
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MY Of ILA
Quirita
• v TOTAL • '
FEE •
fS O U
VALUATIONS
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.
❑
OP'NO.
ADDITIONAL INFORMATION
/
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
126 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 PA
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
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Trt� of '14a(Quinta
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This Certificate issued pursuant to the requirements of Section 306 of, the Uniform Building
Code certifying that at the time of issuance this structure was in compliance with the various
ordinances of the City regulating building, construction or use. For the following:
BUILDING ADDRESS 78-451-, Hwy '11
Use Classification Office Bldg. Permit No. 673
VN
Group B2 Type Construction Fire Zone Use Zone SR
Owner of Building N/A Address
City
Building Official
BY; Phil Coggins
Date April 20, 1984
POST IN A CQiJ8"CU0'US PLACE