0480 (COMB)"' 7 V
PERMIT APPLICATION
t�' ..�^ tiY! �xJLfz,'•
City of La Ouinta .
' Department of Building and Safety ✓�N�
.This permit becomes void if work not commenced within 180 days -from date of issuance;.OR,
if work has been suspended or abandoned for a period,of•180 days.. '
.PRC
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.otChapter ;9 7
the permit is for ane hundred.($100) o, less. I certify that in the performance of the work for which this permit is _
• (commencing with Section •7000),of Division Sof the Business and Professions Code, and my license is in full force. ' , :• -.r
issued, I shall not employ any person in any manner so as to become subject,to the Workers'Compensation Laws of
and effect.
California.
License Class Lic. Number
Date Applicant
' Date'- ' Contractor
NOTICE TO APPLICANT: II, after making this Certificate.of Exemption, you should become subject to the,Workers'. r;..
' I • ••
OWNER•BUILDER DECLARATION' I'hereby:alfirnl 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.— • .
'revoked r
following reason (Sec. 7031.5. Business and Professions Code: Anycity or county which requires a permit to
be deemed
construct, alter, improve, demolish, or repair, any structure, prior to its issuance, also requires the applicant for ,
DIVISION OF INDUSTRIAL SAFETY. PERMIT CERTIFICATION'... ,
•; suchpermit:tofileasignedstatementthatheislicensedpursuanttotheprovisionsoftheConlractor:s license Law.-
p"I hereby tierlify that,no excavation five (5) or riloie fe*et.in depth into Which a person is required 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 exemptikn ny violation of Section 7031.5 by any applicant for a permit - ,
deinolition-or dismantling.thereot, will be more than thirty-six (36) feet high. (Chap 3.2;Grp 2, Art 2; Sec341,,Title 8, • .
subjects the applicant to a'civil penalty of not more than. five hundred dollars ($500.):
"C.A.C.)''
• ❑ 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
through his own employees, provided that such improvements•are not intended or offered for sale. If; however, the. n •'
❑.Division of Industrial Safety Permit No.
buildingorimprovemntissoldwithinoneyearofcompletion,theowner-builder will have the burden of proving that
Date'Applicant
he did not build.or improve for the purpose of sale:).
CONSTRUCTION LENOING'AGENCY: I hereby affirm thatthere is a construction lending agency for the performance'
❑ 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' - 1.
builds or improves thereon, and who contracts forsuch projects with a contractor(s) licensed pursuant to the..
.
Contractor's License Law.). t._
Lender's Address
' . O I 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 building construction, and hereby authorize representatives ,
' of this county to enter upon the above-mentioned property for inspection purposes.
WORKERS' COMPENSATION DECLARATION: I herebyaffirm that I have a certificate of consent to self -insure, or a '
certificate of Workers' Compensation Insurance , ora certified copy thereof (Sec; 3800. Lab: G).
Signature of`Appliclnt or Agent Date
Policy No. Company,
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that _
O. Certified.copy is hereby furnished. ..rs . -
the information given is correct. I agree to comply with all state laws and county ordinances relating -to buidling .. .
O Certified copy is filed with the City Building Inspection Department of City Department
construction, and,authorize a' representative of the City of La Ouinta Department of Building and Safety to enter
` * ": fj
upon ttie property for which I have applied for this permit for the.purpose of making inspections.
Date jam, s Applican�
Signature of Applicant or Agent Date
_
Print Applicant/Agent Name ,
APPLICANT NAME -n. F,MI)M
lt
ADDRESS
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CITY�hCyyOMMU1NIITY/STAtEJZIP ..
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JOB SITE ADDRESS/SPACE /
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CITY/COMMUNITY/STATE/ZIP ,
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TRACT
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TRACT NAME t
OWNER NAME (L. F. MI)--•j7�",
1, Ek � WA AJC /"/4A 5 i( 164- e1645)
CONTRACTOR -FIRM NAME .
ADDRESS
CITY/COMMUNITY/STATE/ZIP ..
PHONE 1 '
LICNC
7
ARC/ENG FIRM NAME +
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE
LICNC 0
..
USE OF PERMIT/ /
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END
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J A 116 1983
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4 x • .. K 'TOTAL "
BLDG.DEPT.
FEE �'�7w 41!1. •.
VALUATION 15-7
:4,r
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
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
7 O y
l
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath � S/ �!/'1�_
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
126 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
Tank Pit- L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
p/L P/I
STREET NAME
26 Power Pole
27 Conduit
28 `Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final