0062 (RPL)APPL_- ICANT NAME (_- L, F, MI)
'
• ,.
- PERMIT APPLICATION r`
—_,a` r .. ` ...... City ot'La Ouinta....
Department of Building
and Safety
PRC
_ This permit becomes void if work not commenced within 180 days from date of issuance,
OR, if work has been suspended orabandoned for :, period of 180 days. fy,
•
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 tha: in 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 mannerso ae to 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 O 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 f rthwith comply with such provisions or this permit shall
following reason (Sec. 7031.5. Business and Professions Cotte:, 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 CERTIFICATIC N:
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law
(D I hereby certify that no excavation five (5) or more feet in depth into whicha 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,.and that no building structure, scaffolding, fals'ework, 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 thirt_•-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341, Title8.
subjects the applicantto a civil penalty of not more than five hundred dollars ($500.):
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
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.
buildingorim rovemntissoldwithinone ear ofcom completion, will have the burden of proving that
P Y P P 9
Date Applicant -
he did not build or improve for the purpose of sale.).
�=
CONSTRUCTION LENDING AGENCY: I hereby affirm that Crere 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. 1 iv. C.).
7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
4'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. I agree to comply with all
Dale 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 I have a certificate of consent toself-insure, or
•
certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. C.).
Policy No. Company
Signature of Applicant or Agent Date _
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read thisapplicationand sta.�te that
O Certified copy is hereby furnished.
the information given is correct. I agree to comply with :ll state laws and county ordinances relating to buidling ,
O Certified copy is filed with -the City Building Inspection-0epartmentt or)City ••- -Department.
�Gc^�'<Y}-' �
construction, and authorize a' representative of the City,of La Ouinta Department of Building and Safety to enter
the for I have for this for inspections.
Date c d Applicant ' Irv. ���
upon property which applied pernit the purpose of making
APPL_- ICANT NAME (_- L, F, MI)
ADDRESS
P. O. Box 780
CITY/COMMUNITY/STATE/ZIP
La Quinta, CA 92253'
JOB SI E ADDRESS/ PACE
50- c Lit; &*=ita .
CIT^/CO
4(y1G MMU_ NITE/Z
'PAGE+ ta, _IP 92253
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OWNER NAME (L. F. MI) - -
CONTRACTOR -FIRM NAME -
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PaUumffi9H,;P Ch 92260 '
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ARC/ENG FIRM NAME ..
ADDRESS o
CITY/COMMUNITY/STATE/ZIP
PHONE # .
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USE OF PERMIT ^ -
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SSB
SSB
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END
` SIDE --
Arrow Printing 250/1-83
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMTj� r ,1DATE•�_p3 _
t Per 'Plan
/Pennii
�a�n.+,i. j , }�uipnent
C orftalc to iWLiAJ sh vbr)mai4 • Unpi
Plan Lack 22 Ax- � ' s
spa pamit 45.010"
• • L r • {,..•' %-yam
a. TOTALr�
FEE
White_ Finance_ :Canary: Assessor- Pink: Applicant Tag: Bldg. Dept.
VALUATION .�3rpo 00 �� .
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.
❑
NON
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 (Blo
14 Final
PLUMBING PROVALS
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
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
PSL P/L
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final