000925 (SFD)PERMIT APPLICATION
City of La Ouinta
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 for a period of 180 days.
LICENSED CONTRACTORS DECLARATION: 1 hereby affirm that I'am licensed under provisions of Chapter 9
(commencing with Section 7010) of Division 3 of the Business and Professions Code• and my license is in full force
and effect.
License Class
Lic. Number
Date Contractor
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License taw 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 fora permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
?.mr 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, 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
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.).
0 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 contrac st for suchprojects with a con)rattor(s) licensed pursuant to the
Contractor's License Law.).
❑ I amexemptunder Sec. �"✓� � , r / � B". 8 P.C. (Attached Certificate).
Date Owner
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.). •
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
APPLICANT NAME (L, F. MI) '
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ADDRESS �- S
5A-102 R11M�l 4 41a Hi c+ %M4 �4'.711
CITY/COMMUNITY/STATE/ZIP
.?l r*%i 1191*'? rA Q9251 "
JOB SITE AOORESS/SPACE
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CITY/COMMUNITY/STATE/ZIP "
T_!ii a 79;
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TRACT NAME Y�
OWNER NAME (L. F. MI) Will DWe1o*ent
CONTRACTOR -FIRM NAMEh
owner
ADDRESS abow '
CITY/COMMUNITY/STATE/ZIP
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PHONE•
564-64487
cityof La Qilil' Lo
ci,77
LICNC /
ARC/ENG FIRM NAME Patxick Mie ft
ADDRESS
74-215 Idy 121
CITY/COMMUNITY/STATE/ZIP '
Palnp esert, CA 92260
PHONE •
346-0596
LICNC 8
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1.END
SIDE
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
the permit is for one hundred ($100) o, less. I certify that in the performance of the work for which this permit is
issued: I shall not employ any, person inany manner so as to become subject to the Workers' Compensaf on Laws, of f
California_ ", F r� / /y/ %r' /js 1
Date , ` l f' '� Applicant .r r/��/A / �� ,
NOTICE TO APPLICANT: If, after making this-Certificate'of Exemption, you should become subject to the"W1.4s'
Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this pe mit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
0 [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-six (36) feet high. (Chap 3.2. Grp 2. Art 2. Sec341. Title B,
C.A.C.)
tO As owner -builder. I will not employ anyone to do work which would -'require a permit from the Division of
Industrial Safety, as'noted above, unless such person has lq permit to Itsuc t fork fr m thadivision. .
0 Division of Industrial Safety Permit No. z l' _ 4 �►•
Date Applicant--+��. � w
` V a
CONSTRUCTION LENDING AGENCY: I hereby affirm Ihat there is a construction lending agency for tboperformance
of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Addre
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 bate
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
the information given is correct. I agiee to comply with allstate laws and county ordinances relating to buidling
construction, and authorize a'repiesentative of !Pe City of La Ouinta Department of Building and Safety to enter
upon the property for which have applied for this permit for the purpose of making inspections.
< ��tr /l ' 1/ /�`i� ^V r
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPUPRMT nn DATE
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TOTAL
FEE
11,241.03
BLDG. DEPT. VALUATION 11112 -577 -An
Ah
Ah
NO.
OPERATION I ATE
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
35
Furnace Compart.
3
Steel
36
Inlets & Outlets
4
Grout Blocks
37
Combustion Air
5
Bond Beams
38
Compressor
6
Roof Deck . •
39
1 Appl. Clearance
7
Framing
ejAohv
40
1 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.
❑
OP'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 Q ,�
'
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