0585 (PLBG)PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
This permit becomes void it work not'commenced within 180 days from date of issuanr,¢, OR; if'work has been suspended or abandoned for a period of 180 days.
ADDRESS - r-
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
dhe permit is for one hundred ($100)'o, less. I certify that imthe'performance of the work for which this permit is
(commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force.
issued, Ishall not employ any person inany mannerso as to become subject to the Workers'Compensation Caws of
and effect.
California.
License Class Lic: Number l
Date. Applicant
t
Date ' Contractor,-
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you'should become subject to the Workers' -
' OWNER -BUILDER DECLARATION: I hereby alfirm lli$ I m exempt 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 r
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 heislicensedpursuanttothe provisions oftheContractor'sLicenseLaw .
❑ 1herebycertifyfhatnoexcavationfive (5)ormore feet'indepthintowhich aperson isrequired todescend, will be
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) or that he is exempt
made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or
therefrom and the basis for.the alleged exemption: Any yiolafion of Section 7031.5 by any applicant for a permit
demolition or dismantling thereof, will be more'than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341,-TitfeB, .
subjects the applicant to a civil penalty of not+more than five hundred dollars ($500.):
C.A.C:)' `
0 1, as owner of the property:.ar my employees with wages -as their sole compensation, will do the work, and the
❑ 'As owner -builder, -I wilP'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, or improves 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 ..
0-Divisign of Industrial Safety Permit No. +--
• building orimprovemntissoldwithinoneyearofcompletion.theowner•builderwillhavetheburdenofprovingthat„.,, •.
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
- , O I, 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. 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
❑ 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 andstate.laws relating to building construction, and hereby authorize representatives „
LOT SZ.•
of this'county to enter upon the above-mentioned property tor'inspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent -lo 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
CERTIFICATEOF COMPLIANCE AND AUTHORIZATION OF. ENTRY: I certify I have read this applicatioriaitd state that
o Certified copy is hereby furnished. :arL •z
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
❑ Certified copy is filed with the City Building Inspection OepartmeO or City - Department:
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.) have applied for this'permit for the purpose of making inspections.
Signature of Applicant or Agent Date
APPLICANT NAME (L. F, MI) ' .
4,47,CZANLSD 25`T.
ADDRESS - r-
CITY/COMMUNITY/STATE/ZIP -
JOB SITE ADDRESS/SPACE -
7fr V7 /-lz-L-;F AF410
CITY/COMMUNITY/STATE/ZIP
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TRACT NAME '
OWNER NAME (L. F, MI)
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CONTRACTOR -FIRM NAME '
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE •
LICNC •
ARC/ENG FIRM NAME '
ADDRESS
CITY/COMMUNITY/STATVZIP • - -
PHONE •
LICNC ♦
USE OF PERMIT -
BL
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FSB
SSB
SSB •
RSB
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ZONE ORD •
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END
SIDE '
Print Applicant/Agent Name
APPUPRMT r�■{�•�■■■ )/DATE
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T 70 IA157444
A/r DAJ
50s7,e At�. ASC C0D,6' _
A4 tlln 6 "V4
TOTAL'•
FEE -
BLDG. DEPT. VALUATION
' `' -
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.
❑
NPON
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 2115
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
P/L PiI
STREET NAME
26 Power Pole•
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final