001172 (PAT)' - PERMIT APPLICATION
City
of La Dg
' Department of
a
Building and Safety
PAG
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..
TWN -
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
LICENSED CONTRACTORS DECLARATION: I hereby affirm that Iam licensed under provisions, of Chapter 9 . •
=, the permit is for one hundred ($100) it, less. I certify that in the performance of the work for which this permit is
(commencing with Section 7000) of Division .3of the Business and Professions Code, and my license is in lull force
issued,.) shall not.employ any person in any manner so asto,become subject to the.Workers'CompensationLaws of K .
and effect.
California.
License Class Lic. Number �� — !7
, Date Applicant _
���
Date - Contractor 't•% .C.��,.Lr`�_ ��•=�-r "'~_ -
` NOTICE TO APPLICANT: If, after making this Certificateof-Exemption, you should become subject to the Workers' -
/Compensation
OWNER -BUILDER DECLARATION: I hereby affirm that I am, exempt Trom the Contractor s License law.for,the = '"
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 y
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 asigned statement, thatheislicensed pursuanttothe provisions ofthe Contractor'sLicense Law
'•:01hereby certify that noexcavation five '(5)ormorefeet indepthintdWhich aperson isrequired todescend, will be
(Chapter 9(commencing.with section 7000) of Division 3 of the Business and,Protessions Code)orthat he is exempt :..
made in connection with work authorized by this permit; and that no building structure. scaffolding, fafsework, 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 thirty-sifl36pfeet high: (Chap 3.2, Grp 2: An 2, Sec341, Title 8: '
subjects the applicant to a civil penally of not more than five hundred dollars ($500.):
C.A.C.) •` -
A I, as owner of the property, or employees with wages as their s.ole,compensation, will do the work, and -the..
❑ 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. 7D44, 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, arid who does such work himsell or
o-
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.
building orimprovemnt is sold within oneyearof completion. the owner -builder will have the burdenofproving that
Date • Applicant
. he did not build or.improve for the purpose of sale.). , -
CONSTRUCTION LENDING AGENCY: Neir'eby affirm that there is a construction lending agency for the performance
0 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,
7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of.property who
Lender's Name
builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the
Contractor's License Law.). _
Lender's Address
0 1 am exempt under Sec.• B. 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.
Date' v, 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 hereby affirm that I have a certificate of consent to self -insure, or a
certificate of Workers' Compensation Insurance'; or a certified copy thereof (Sec. 3800. Lab. C.).
Si nature of Applicant or A
Agent i e
9 pP enc Dat
Policy. No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that •' a
0 Certified copy is hereby.furnished., s
�. .:... the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling' ..
0 Certified copy is filed with the City Building Inspection'Departmint or City Department.,
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 permit for the purpose of making inspections. -
Date Applicant
__•� iignvre�o i`Ai DPIicant or�AOen Al Date
Print Applicant/Agent Name
APPLICANT NAME (L, F. MI) Landmark. . , -
ADDRESS P.0.'Boxy 1000 -
CITY/COMMUNITY/STATE/ZIP La Quanta, CA 92253 -
JOB SITE ADDRESS/SPACE 78-178' Calle NOrte .
CITY/COMMUNITY/STATE/ZIP La-!luLAiltbGi .•is.t , CA 92253 .
BOK
PAG
PRC
C
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PING .
SE '1,S
38.50
T1A5T767
IL
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MOD
S13
TRACT NAME Duna* La 0iinta , ,
k�-.��
OWNER NAME (L. F. MI) Kearny
CONTRACTOWFIRM NAME Applicant -
��+..L..»v.
ADDRESS :
- ,
CITY/COMMUNITY/STATE/ZIP abolue
PHONE II
LICNC .
-ARC./ENG FIRM NAME
ADDRESS .
CITY/COMMUNITY/STATE/ZIP
PHONE 1
'LICNC..
,
USE OF PERMIT Patio o *Cove ,
BL,
'ZON
'FSB •'
SSB
SSB
RSB
OFC
' ZONE ORD -. , :.
LOT SZ
-
END.
• SIDE .
APPVPRMT ....10A'15
-SS ELDG. -
Permit to cwn$truct patio oover as per
"approved plans.
Plan bl eck
25.02 -
Const. Fee
38.50
SMI Fee
.50 -
TOTAL
FEE
BLDG. DEPT. VALUATION
- - - -
A
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) -
i
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
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