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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