001153 (BLCK)r. .
'LICENSED CONTRACTORS DECLARATI
(commencing with Section 7000)01 Divi
and effect.
License Class Lic. Number
Date Contractor
OWNER -BUILDER DECLARATION: I -hereby affirm that I am exempt from the Contractor's License Law for the -
following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, alter, improve. demolish• or repair any structure, prior to its issuance, also requires the applicant for
such permit to file a signed statement that he is licensed pursuant to.the provisions of the Contractor's License Law
(Chapter 9(commencing with section 7000) of Division 3 of the Business and Professions Code) or that he is exempt
therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
0 I, as owner of the property or my employees with wages as their sole compensation; will do the work, and the
structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Law does not apply to an owner of property who builds, or improves thereon/arid who does such work himself or
through his own employees, provided -that such improvements are not intended or offered forsale. If, however, the
building or improvemnt is sold within one year of completion, the owner -builder will have the burden of proving that
he did not build or improve for the purpose of sale.)
O I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec:
7044• Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the
Contractor's License law.).
0 lam exempt under Sec. � 8 P.0/(Altayhed Certificatl).
'Date Owner �lGv� .
WORKERS' COMPENSATION DECLARATION: I hereby ffirm that I have a certificate of consent to self -insure, or a
certificate of Workers' Compensation Insurance 9 a certified copy thereof (Sec. 3600. Lab. C.).
Policy No. Company
0 Certified copy is hereby furnished. _
.0 Certified copy is filed with the•City Building Inspection Department or City - Department.
Date Applicant
PERMIT APPLICATION
City of La Ouinta i► 'C
Department of Building and Safety
This permit becomes void if work not commenced within 180 days from'date.of issuance. OR, if work has been suspended or abandoned fora period of .180 days.
. . CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed it -
ON: I' hereby affirm that I am licensed under provisions of Chapter 9 'ttte permit is for one hundred ($100) o. less. l certify that in the performance of the work for which this permit is
Sion Sof the Business and Professions Code, and my license is in full force issued,.l shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of
California.
APPLICANT NAME (L. F. MI) 4ohn Bowman
ADDRESS '
54-665 .Avenida Juarez
CITY/COMMUNITY/STATE/ZIP
La Quin&a, CA 92253
JOB SITE ADDRESS/SPACE '
above
CITY/COMMUNITY/STATE/ZIP La .Quinta, CA 92253
BOK
PAG
PRC
C
TWN
RNG
SE '
S
TRACT.
LOTS
MOD
SB
-
TRACT NAME none
OWNER NAME (L. F. MI) Applicant
CONTRACTOR -FIRM NAME Applicant
ADDRESS above
CITY/COMMUNITY/STATE/ZIP
above
PHONE •
LICNC •
ARC/ENG FIRM NAME '
ADDRESS
CITY/COMMUNITY/STATE/ZIP - -
PHONE 11
LICNC ♦
-
USE OF PERMIT
Block Wall
BL
ZON
FSB
SSB
SSB
RSB
OFC
ZONE ORD •
- LOT SZ
-
:.END
SIDE.
Date Applicant
NOTICE TO APPLICANT:.If,.after making this Certificate of. Exemption,: you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall'
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
0 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be
made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or
demolition or dismantling•thereof, will be more than thirty-si`z (36) feet high: (Chap 3.2, Grp 2, Ail 2. Sec341, Title B.
C.A.C.)
-O As owner -builder, I will not employ anyone to do work .which would require a permit from the Division of
Industrial Satety, as noted above, unless such person has a permit,to do such work from that division.'
.0 Division of Industrial,Safety,Permit No.
Date Applicant
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
of the work for which this permit is issued (Sec: 3097, Civ. C.).
Lender's Name. `
Lender's Address
I certify, that I have read this application and state that the above information is correct. I agree to comply with all
-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.
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION' OF ENTRY: I certify l have read this application and state that
the information given is correct. 1 agree to comply with all state laws and county'ordinances relating to buidling
construction, and authorize a•'representatih of the City of la Ouinta Department of Building and Safety to enter
upon the property f r which I have,apptd forthis•p rmit.for the purpose of making inspections.
�1'�� Ja. Nit-!/fll4�
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPL/PRMT n n l i s„ 1 OATE'f 0- 8 Y BLDG.
Permit to construct 215 lin. it. of
6' high block wall as per approved
plans and app. codes and ordinances.
Pian Check 36.72
Permit 56.50
0--
SMI Fee . 50--
nu1984
TOTAL .
FEE
9 3.7 2
BLDG. DEPT.
VALUATION 5,375.00
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION I 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 r
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)
128 Ceiling (Batts)
12C Ceiling (Blown)
14 Final i
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
PSL PiI
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final