0301 (BLCK)PERMIT APPLICATION ;•,�'� 1�
City of La Ouinta d
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. -
_ - .. . • . ' ' `n; • .., . - M
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be.compfeted if .
,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 tEat in the -performance ol,the work for which this permit is=
(commencing with Section']000) oDDivision 3ofthe Business and Professions Code, and my license is in full force,'
issued, Ishall not employ any person in any mannerso is to become subject to the Workers'Compensation Laws of '
and effect.
California.
License Class Lic. Number
Date Applicant
' Date Contractor. - ^- -e --' •- '
NOTICE TO APPLICANT: It, after making this Certificate'of Exemption, you should become subject to the Workers'
OWNER -BUILDER DECLARATION: I hereby affirm that I am •exempt from tileConiractor's License Law for the
Compensation provisions of the Labor Code, you _muslforthwith comply with such provisions or this permit shall `.
following reason (Sec: 7031.5. Business and Professions Code: Any city or'county which requiresa permit.to
bedeemedrevoked..
• consiruct, 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 ptovisions of the Contractor's License Law .�
b I hereby certify that no'eicavation five (5)or m6re feEt in depih into which a person is requiied to descend, will be
(Chapter.9 (commencing with section 7000) of Division 3 of the Business and Professions Code) or that Nets exempt
'made in connection with work'authorized by this perms, and that no building structure, scaffolding, fal'sework•, or
therefrom and the basis for the alleged exemption:'Any violation of Section?7031.5 by any applicant for a permit
demolition or dismantling thereof, will be ioore than thirty-six (36) feethigh. (Chap 3.2, Grp 2, Art 2, Sec341:.TitleB,
subjects the applicant to a civil penalty of not more than five hundred dollars.(MO.)':
C:A.Cj
0.1. as owner of the property, or my employees with wages as their sole compensation, will do the work, and the.
❑ 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 Contractors 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
ADDRESS '
through his own employees, provided that such,improvements are not intended or offered for sale. If, however, the,
❑ Division of Industrial Safety Permit No.
building orimprovemntissold within one year ofcompletion. the owner -builder 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 thatthere 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. ..
.. of'the work for which this permit .is' issued (Sec. 309T 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
- .- -
Contractor's License Law.)..
Lender's Address
• ❑4am exempt under Sec. ^B. &-P.C. (Attached Certificate).
I certify that have read this application and state that she above information is correct. I agree to comply,wilh all
r , •?(r• (j 7s f'
'•�'� 7•F Owner N � u .,'1"•
cit and count 9 9 Yrepresentatives.
Y county to construction, and authorize
%Date
( 1 / - r
WORKERS' COMPENSATION DECLARATION: Ihereby affirm that I have a certificate of consent to self -insure, or'a
of this'county to enter upon the above-mentioned prorerty.lor inspection purposes:
;`certificate of Workers' Compensation Insurance': or:a certified copy'thereof (Sec. 3800. Lab. C.).'u
Signature of Applicant or Agent Date
Policy No. Company.
CERTIFICATE OF COMPLIANCE AND AUTHORIZATIONOF ENTRY: I certify I have read this application and state that
. , ❑ Certified copy is,hereby. furnished. • . -. ,
the information given is correct. I agree to comply will all state laws and county ordinances relating to buidling
❑ Certified copy is filed with the City Building Inspection Department or City Department.
construction, and authorize a' representative of the Ci y of La Ouinta Department of Building and Safety to enter..
upon the property' which I have applied for this permit for the purpose of making inspections:
— Date Applicant
Signature of Applicant or Agent Date
APPLICANT/NAME (L. F. 1019e
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
/_/, 4!: 5/
JOB SITE AODRESS/SPACE
CITY/COMMUNITY/STATE/ZIP - -
BOK -
PAG
PRC
C
AUG 2 9 1983'
TWN
RNG
SE
S
TRACT
LOTMOD
SB
TRACT NAME '
OWNER NAME (L. F. MI)
CONNTRRACTOXFIRM NAME
ADDRESS•
CITY/COMMUNITY/STATE/ZIP
PHONE P '
LICNC •
ARC/ENG FIRM NAME
ADDRESS '
CITY/COMMUNITY/STATE/ZIP
PHONE*
LICNC
USE OF PERMIT
BL
ZON
FSB
SSB
SSB
RSB
OFC.'
- ZONE ORD N' •�
LOT SZ
END
": SIDE
Y
Print Applicant/Agent Name
APPL/PRMT T �e�
• r
D
AUG 2 9 1983'
City of. La Quinta
A 11 AM --
LJ
TOTAL
FEE
VALUATION
BLDG.DEPT.
NO.
OPERATION DATE INSPECTOR
NO.
OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
1
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. ❑
N
NO.
O.
ADDITIONAL INFORMATION
!/ `� �•IX�% !!
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 / o137?
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
PSL Pyl
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
296 Bonding
30 Fixtures
31 Service
32 Final