0064 (RPL)L` F�M�I)
ADDP.SS0r Bm 780 � ..
PERMIT APPLICATION
'' 1
c City of La Ownta
Y•
Department.of.Building
and�Safety
PRC
This permit becomes void if work not commenced within 180 days from date
of issuance, OR, it o k'has been suspended or abandoned for a period of 180 days: �' ' ti•. —
r
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION 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 is 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 inany manner so astc 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=xemption, you should become subject to the Workers' '
OWNER -BUILDER DECLARATION: 1 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.
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 asigneqstatement that he is licensed pursuant to the provisions of the Contractor's License Law
❑ Iherebycertifyt6atnoezcavationfive(5)ormorefeetin9epthintowhichapersonisrequiredtodescend,willbe
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,same, ^
or
therefrom and the basis for thea any applicant for a permit
eof not mo Any violation of Section 7031.5
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341, Title8. ^
•-
malt
subjects the applicant to a civil penally of not more than five hundred dollars ($500.):
0.
C.A.C.) -
O 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, 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 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
— 'A J.
through his own.employees, provided that such improvements are not intended or offered for sale. If, however, the
O Division of Industrial Safety Permit No.
buildingor improverrint is sold within one year of completion, the owner -builder will have the burden of proving that
Date Applicant '
he did not build or improve for the purpose of sale.).
T
CONSTRUCTION LENDING AGENCY: I hereby affirm that the±e 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, Ci.. C.). —
7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
LOT SZ
builds 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. & 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
Date Owner,
city and county ordinances and state laws relating to build big construction, and hereby authorize representatives
of this county to upon the above-mentioned propert-r for inspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, ora
�enter .
-
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 EN—IRY: I certify I have read this application and state that
O Certified copy is hereby furnished.
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling ,.
O Certified�.Wcopy is filed with the City Building Inspection Department or City Department.
construction, and authorize a'representative of the City oS La Ouinta Department of Building and Safety to enter
Ci
Date "% ` �w / �yApplicant F' d� -� f ,✓:y2� I '^l 9
.� -
upon the property for which I have applied for this permidfor the purpose of making inspections. .
Signature of Applicant or Agent 'Date
Print Applicant/Agent Name _
APPLICANT NAME
1willy(
APPL/PRMT 'iL"�e fi•,• .( ,,jj .. DATE
L
L` F�M�I)
ADDP.SS0r Bm 780 � ..
CITY/COMMUNITY/STATE/ZIP
La eta, CA 92253
Jo5gTE AUJRESS.s e nor
CITY_/COMMU-_ NIJY/STATE, M S� -
ibPPAA��G'fD r•� M�
BOK
PRC
C
_
r'
°
TWN,
AND
SE
S
TBT A96•.�.
1
LOT
MOD
56
TR�`
NCS . Clove SC '
OWNERNAMEIL. F. MI)
CONTAAMilll T,OR-SRM.NS_E . Is
ADDRESS14—;222 Highway 11.1.
C1. Y�rCOMM�jUMMt/Y STA•E/ZiCA
804
q
13M45
I
ARC/ENG FIRM NAME
ADDRESS ,
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC #
USE OF PERMIT
BL
ZON
FSB
SSB
SSB.
RSB
OFC
„ ZONE ORD M
LOT SZ
FEND
SIDE_ .
Pemit for Spa and &.,pipmnt Eer PT.mv
(3ent.-act= to Fumish wbrkmani s E3mp.
Plan Cic/k S 22.95' '
spe Permit 45';00,,-:'1'.
i
I P •
.. `. ..
NOTAL -67..25'
" FEE
.VALUATION i
Arrow Printing 250/,tr83 < White: Finance Can Assessor, .Pink: Applicant Tag:yBldg.�Dept. v .
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.
❑
NO.
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 ow
r"
14 Fin c fjj/J
PLUMBING P(PPFC6VA1CS
15 Grou umb
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 PAI
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
I