000965 (SOL)APPLICANT NAME (L. F,/MI)
ADDRESS
_5 /- 2,3 to im
PERMIT
APPLICATION
of LLaquintaG2/�L� vE
Department of
Building and Safety
a ely
PAC
-C
-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.
r
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not The completed it
T 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 Divisioh Sof 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.
4 1� �5_eT
I'
License Class Lic. N.mb,r4
Date or .5a
Date Applicant
NOTICE TO APPLICANT: if, after making this Certifi6ati.of Exemption, you 'should become.subject to the Workers'
'6WNER.iVILDER DECLARATION:. I hereby affirm that I am exempt from the Contractor's License Law for t6e
*Compensatio.n.provisions of the Labor Code, you must forthwith comply With.such provisions or this permit shall
following reasqn'(Sec.:7031.5. Business and Professions Code:. Any city or county which requires a permitto'6e
deemed revokid.
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 sigRed.state.ment that he is licensed pursuant.to the provisions.of the Contractor's License Law
0 1 hereby certify that n . o excavation five (5) or more fiet in depth into which a person is required. to descend, will be
(Chapter 4 (commericirtgwittf section 700.0) of Division 3 o the Business and Professions Code) or that he is exempt
'violation
.-.Made in connection with'Work authorized by this permit, and that no building structure, scaffolding, falsework, or
therefrom and the bas is.for the, alleged exemption. Any of Section 7031.5 by any.applicant for a permit.
dimolition or dismantling thereof. will be-rhore than thirty-six (36) feet high. (Chap 3.2, Grp Z Art 2, Sec 341, Title 8. -
e•Fsubjects the applicant to a civil penalty,of not more;than,five hundred dollars (MO.):
C.A.C.) .
.0 Las owner.,of the property, or my employeps7with wages as their sole compensation; will do the work, and,,the •
b As 'o wrier -builder, I will -not employ anyone to do work which wouldriq6ire 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 divisioln.,
Law does not apply to an owner of property who builds, or improves thereon, and who does such -work himself or
.11-1 . . . . . . .:11 . I
through his own employees, provided that such'ItYiprovements are not intended or offered for -sale. It, however, the
O. Division of Industrial Safety:Permit No.
building or improverrint is sold.within one year of completion. the owner_oMilder will have the burden of proving that.
"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
.0 1, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec.
ot the work for which this
D -1c issu!tl=�,C,,).,.
7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who -
ender 's Name' If i "V"� p7
builds or* improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the
U Pi
Coniractor's License Law.).
Lender's Address 144
0 1 am exempt under Sec. B..B P:C. (Attached Certificate).
I certify that I have read this application and,slate that the above information is correct..) agree to comply with all
Date" Owner
w city and county ordinances and state laws relating to building construction, and hereby authorize representatives
of/this,cou tj' to nte'U poabove�mentioned proper inspection purposes: ty
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a
e., : I ! .
;te
certificate of Workers' Insurance lora certified copy thereof (Sec. -3800. Lab. C.).-
&9• 5r
S•i ghature of ApplicAt or Agent Date
Policy No/�v _/1Z Compa'��_16;64 ."2*1
ertified copy is furnished.
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read thisapplica iona ' nd.s a e ha
the information given is correct; I agree to comply with all state laws and county ordinances relating4o buidlin
'hereby
0 Certified copy is filed With the City Building 16spection Department or City Department.construction,
and authorize,a *representative of the City of La Ouinta Department of Building and Safety to enter
upon the property for which [,have applied for this permit for the,purpose'of making inspections.
Date Applicant
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPLICANT NAME (L. F,/MI)
ADDRESS
_5 /- 2,3 to im
CITY/COMMUNITY/STATE/ZIP
A.4 0t.i,u—,pA
JOB SITE AODRESS/SPACE
:5,qMe
CITY/COMMUNITY/STATE/ZIP
SOK
PAG
PAC
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TWIN.
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SE.- JlS.
TRACT
I LOT
I'
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J,SB
TRACT NAME -
OWNER NAME (L. F. MI).
CONTRACTOR -FIRM NAME
V
ADDRESS
CITY/COM71TY/STATE/ZIP
0"n( ,4
JAY -4
PHONE*
CNC
ARC/ENG FIRM NAME . .....
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 4
LICNC
USE OF PERMIT 5>1 Wil. ta
131.
ZON
FSB
SSB
RSB
OFC
ZONE ORD a
LOT SZ
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''SIDE.
APPUPRMT
DATE
7
A
TOTAJL
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.
❑
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
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