001165 (SOTB)PERMIT APPLICATION
City
of La Ouinta r
i .•.,. Department of
Building and Safety
This permit becomes void if.work not comrnenced.within 980 days from date
of. issuance.'OR; if work has been suspended or abandoned for a period of 180 days.
'
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE:.This section need not be completed if •.
LICENSED' CONTRACTORS DECLARATION: Ihereby affirm that I' am licensed under provisions, of Chapter•9.
.. 'the.permit is for one hundred ($100) or less. I certify that 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 manner so asto become subject to the Workers' Compensation Laws of
and effect.
California. ..
License Class L'cr,N/i�mmmpppyer.
Date Applicant
Date Contractor' //�� r � Y"�
NOTICE -TO APPLICANT: IL after,making this Certificate of Exemption, you should become subject to the Workers''
0WNER•BUILDER DECLARATION: I hereby affirm that I"am 'exempt '9rom 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. Busidess and Professions Code: Any city -or county which requires a permit to .'
:. be deemed revoked.' _ •. • •y,
construct, alter, improve; demolish, or repair any structure, prior to its issuance: also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: -
such;permittofile,asigned statement that he is licensed pursuani to the,provisions of the Contractor's License Law
❑ 1herebycertifythat noexcavationfive(5)ormore feet indepth into which aperson isrequiredtodescend,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 authorised by this permit, and that no building' structure, scaffolding, falsework, or '
•therefrom and.the basis for the'alleged exemption. Any violation of Section 7031.5 by any applicant for a permit-
:a.z..--:'demolition or dismantling thereof; will 6e more than thirty-six (36) feet high: -(Chap 3.2. Grp 2: Art 2; Sec341, Title B; -
subjects the applicant to a civil penalty of not more than five. hundred. dollars ($500.):
CAC.)
❑ I. as owner of the property, or my employees with wages as their sole compensation, will do the work, and the
El 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 awn employees: provided that such improvements are not intended or offered for sale. If, however, the •'
,0 Division of Industrial Safety Permit No.
building orimprovemntissoldwithin one year ofcompletion, the owner•builderwill have the burden ofproving that _
Date Applicant
. did not build or improve -for the purpose, o('sale.).
CONSTRUCTION LENDING AGENCY: I hereby affirm.that there is a construction lending agency for the performance
01.
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, Civ: C.).•
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.). II I . ,
Lender's Address
y
0 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
Date Owner '
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
' WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have "a certificate of consent to self -insure, ora '
of this county to enter upon the above=mentioned property for inspection purposes.
certificate of Workers' Compensation'Insurance , or a certified; copy thereof (Sec:*,3800. Lab. Q. • .
Signature of 'Applicant or Agent Date
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:.I certify I have read thisapplicationand state that
0. Certified copy is -hereby furnished. . - - -
'the'information given is correct. I'agree to comply with all state laws and county ordinances relating-tobuidling.
❑ Certified copy is)iled with the City Building Inspection. Depa/rtment or fly Department
construction, and authorize a'representative of the City of La Ouinta Department of Building and Safety to enter
�d/�• � ,., - " - , '
upon the property for which I have applied for this permil'for the purpose of making inspections.
Date Applicanll
Signature. of Applicant or Agent Date
Print`Appl c nt'AAgent Name
APPLICANT NAME (L. F. MI) <
ADDRESS ' ' P.O. §o l000 ...
CITY/COMMUNITY/STATE/ZIPLa Quin. ' MA • 92253
'JOB SITE ADDRESS/SPACE 78-165 Celle Norte - ••
CITY/COMMUNITY/STATE/ZIP -
-1 - la Quinta, •C A 92253
BOK
PAG
PRC -
C
9.00
TWN-
•RNG
SE. •.
S
TIU767
LOT
SMI Fee
.50
Pludbing'Fee
30.00
TRACT NAME D,„,�,� TT.� y,, •.
Ll.4I� JJ� Qu.Znta .
OWNER NAME (L. F. MI) ���• -- 1[ rk
CONTRACTOWFIRM NAME ..
Agpl�.catit ' ..
ADDRESS abie
CITY/COMMUNITY/STATE/ZIP
abme
PHONE .
LICNC •
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP - . ..
PHONE I -
179.16. • ,
' LICNC F
USE OF PERMIT Pool -Pas '
BLZON
FSB
SS8 -
SSB"
RSB
OFC,
ZONE ' ORD' . +,.
LOT SZ
END
SIDE'. '
APPI%PRMTn -11 1'l
Li-GAT�S -• .
Permit to build 150
sq. ft. of pool
restroans for public use. All recp.
required to' be on GFI
Niedh. Fee .'t •,
9.00
Plan Check` Fee
59.41
Const. Fee
62.50
Elect. Fee
17.75
SMI Fee
.50
Pludbing'Fee
30.00
TOTAL' '
FEE, •
179.16. • ,
BLDG. DEPTVALUATION 6,300.00 '
• . _ • .
A&
r-1
NO.
OPERATION TATE
INSPECTOR
NO.
OP ATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
34
Plenums & Ducts
2A
Slab Grade / s s
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 (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 P)
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
.29 Wiring
29A Grounding Wire
29B Bonding�fL,�}/� 02 S
30 Fixtures
31 Service
32 Final