0065 (RPL)PERMIT APPLICATION •
ADDRESS
. P. O. eco 780
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.
City of La Duinta ,�� -
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Department of Building and Safety
CITY/COMM UN ITY/STATE/ZI P
La Qiinta, CA 92253
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s This permit becomes void it work not commenced within 180 days from date
of issuance, OR, if"work has been suspended or abandoned for a period of 180 days. 1
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CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSA-ION INSURANCE: This section need not be completed 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 that It the 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, I shall not employ any person in any manner so as become subject to the Workers'Compensation Laws of
and effect. ,
_ ' California. -
License Class Lic. Number
Date Applicant
Date Contractor
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' '
OWNER -BUILDER DECLARATION: I hereby affirm that I am 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
following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
be deemed revoked. _ r.
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: - • " -
suchpermittofileasignedstatementthat he is licensed pursuant to the provisions of the Contractor's License Law
01 hereby certify that no excavation five (5) or more feet if depth into which a person is required to descend. 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, znd that no building structure, scaffolding, falsework, 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 more than thirtysix (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341, Title8,. '
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
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❑ I, as owner o1 the property, or my employees with wages as their sole compensation, will do the work, and the
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❑.As owner -builder, I will not employ anyone to do w. rk 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 h:.s 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
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 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
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builQs or improves thereon, and who contracts for such projects with a contractors) licensed pursuant to the
Lender's Name -
Contractor's License Law.).
Lender's Address
O 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 and state laws relating to buiding construction, and hereby authorize representatives
of this county to enter upon the above-mentioned property for inspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that 1 have a certificate of consent to self -insure, ora
certificate of Workers' Compensation Insurance or a certified co thereof (Sec 3800 Lab C)
'
Policy No. Company
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the, ty Building Inspection Department or City> Department.
Date �' , ' o i Applicant +>�`'
APPLICANT NAME (L. F, MI) yamM
A A.t6MU
ADDRESS
. P. O. eco 780
CITY/COMMUNITY/STATE/ZIP
ISL Quinta, CA 92253
JOB SITE AODRESS/SPACE
50--045 t aUe Ftysarita
CITY/COMM UN ITY/STATE/ZI P
La Qiinta, CA 92253
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OWNER NAME (L. F. MI)
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Y:c:1tiA�1a,1''g}Guui "A.Vd+cJll 8 ..
Ai11-A✓22 `�D ay LU •.
CI� COMY `MUNYI,TLtaTA' E/Z 92253
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PHONE n
346-4804
LICNCM
J204i45
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ARC/ENG FIRM NAME ,
ADDRESS • 1 N
CITY/COMMUNITY/STATE/ZIP
PHONE N ,�
LICNC a
USE OF PERMIT
BL'
ZON
FSB
, SSB
SSB
RSB
- 'OFC
ZONE ORD M
LOT SZ
' TOTAL
FEE
-
ENO
SIDE
-Arrow Printing 250/1-83
White: Finance Canary: Assessor
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF 1 NTRY: I certify I have read this application and state that
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
construction, and authorize a'representative of the City of La Ouinta Department of Building and Safety to enter
upon the property for which I have applied for this per nit for the purpose of making inspections.
Signature of Applicant or Agent
Print Applicant/Agent Name
APPPLIIC+•�•. •
Date
'APPL/PRMT I' i U 5 5 2-2 -83
•
�,
q�uipnt Per Plan
�t for -9,m--ity�yd� E�{
�ryto
�•o
Pim check
� (�.�✓''•1•
Spa �t
, 45.00
' TOTAL
FEE
y4+ �.rJ
-
VALUATION
Pink., 4 Tag: 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.
❑
OWN
NO.
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 (
14 Fin
PLUMBING APPR6VALS
15 Groun mb
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 pill
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final