0853 (BLCK)'
ADDRESS- - -
-2 -2 2-3 G AL kA,
PERMIT APPLICATION
s City of La Quinta
Department
of Building and Safety
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This permit becomes .void if work not commenced within 180 days from date
of issuance, OR, if work nas'been.suspended or. abandoned for a. period of 180 days. _r
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CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: -This section neednofbe completed if':
'LICENSED CONTRACTORS' DECLARATION: I hereby affirm that .1 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 p
"(commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force
'-issued; I shall not employany person in any manner so as to become subject to the Workers' Compensation Laws of •'r'
and effect.
'California. "
•"License Class . Lic. Number
..Date Applicant
Date' •' Contractor -a- -> - --
"•'•
NOTICE.TO APPLICANT: If, after making'this Certificate ol'Exemption, you should become subject to the Workers'-
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OWNER=BUILDER DECLARATION: I hereby affirm that I am exempi`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 - -
be deemed revoked.`
following reason (Sec. 7031.5, Business and Professions Code:'. Any, city or county which requires a permit to
LICNC 1.
- construct: alter, improve. demolish; orrepair 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.
O' I hereby certify f hat no excavation five (5) or more feet in depth into which a person is required to descend, w ill be
(Chapter 9(commencing with section 7000) of Division 3 o the Business and :Professions Code) or that heis exempt
made in connection with'4rork authorized by this permit, and that no building structure, scaffolding, falsework, or
,therefrom and the basis for the alleged exemptionr nyviolation of Section 7031:5 by any appficantfor a permit
Gemolition- or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3:2, Grp 2, Art 2, Sic 341. Title8. ti
subjects the applicant to a civil penalty of not more:than five hundred dollars ($500.):
"C.A.C.)
❑ I. as owner of the property, or my employees with wages as their sole compensation, will do the work; and the.
O As owner -builder, 1 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, orimproves thereon, and who does such work himself or
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through his`own employees,•provided that such improvements are not intended or offered for sale. If. however; the ':
❑ Division of..19dustrial Safety Permit No.
building or improvemnt is sold within one year of completion, the owner -builder will have the burdenof=provingthat-
Date Applicant
S•he did not build or improve for the purpose of sale.).
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CONSTRUCTION LENDING AGENCY:.I hereby affirm that there is a construction'lending agency for the performance 71
❑ .I, as -owner. of the property, am exculsively contracting with licensedcontractorsto construct the project (Sec:.'.
. '_ of'the work for which -this permit'is-issued'(Sec. 3097, Civ. C.). - - • c
'.` )044, 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
Lender's. Name 1
Contractors License Law.).. _. ._..
Lender's Address
❑ I am exempt unGer.Sec: - - �• -R • - . B. 8 P.C. (Attached;Certificate).
..I certify that I have read this application and state that the above information is correct. ) agree to comply with all f'
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city and county ordinances and state laws,relating to building construction, and hereby authorize representatives
Date
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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 conss selself-insure• ora
certificate of Workers' Compensation Insurance , or -a certified copy thereof (Sec. 3800.. Lab. C:). •
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
O Certified copy is hereby furnished.
the'intormation given is correct, I agree tocomply with all state laws and county ordinances relating to buidling ! ,
❑ Certified copy is filed with the City Building Inspection Department or'CityDepartment.
construction,.and authorize a'representative.of the City of La Ouinta Department of Building and Safety: to enter
- Date Applicant
upon the property for which 1•have applied for this permit for the purpose of making inspections.
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APPLICANT NAME (L, F. MI) -
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ADDRESS- - -
-2 -2 2-3 G AL kA,
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OWNER NAME (L. F. MI) -
CONTRACTOR -FIRM NAME
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ARC/ENG FIRM NAME - 'p
ADDRESS '
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Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPL/PRMT S DATE/
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TOTAL
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VALUATION���� .3 i•`
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NO.
OPERATION DATE INSPECTOR
NO.
OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS.
1
Set Back
33
Ventilation System
2
Ftgs & Frms
7 ,
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.
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NOADDITIONAL INFORMATION
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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
P/L 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