000966 (RPL)• 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
• ' '- CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section.need not be completed it' .
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am .licensed under provisions'of Chapter 9 the permit is -for one hundred ($100) o, less. I certify that in the performance of the work for which this permit is
(commencing with Section 7000) o6Division 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 as to become subject to.the Workers'CompensationLaws of
and effect. California.
License Class Cic. Number
%j�LDate Applicant'
+ Date I ci 7 ' f Contractor_`� " NOTICE. -TO APPLICANT: If, after making this Certificati of Exemption, you should.become subject to the Workers' .•
'k • - • - Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall
OWNER -BUILDER DECLARATION: I hereby affirm that t am exempt from the ! Contractor's License Law for the be deemed revoked. -
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 DIVISION OF. INDUSTRIAL SAFETY PERMIT CERTIFICATION:. k -
suchpermittofileasignedstatementthatheislicensed. pursuant to the provisions of the Contra ctor'sLicense Law . 0.1 hereby certify thatno excavation five (5) or more feet indepth into which a person is rdiuired to descend; will be
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) orthat 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 exemptioni,Anyviolation of Section 7031.5 by any applicant for a permit demolition or dismantling thereof, will be more than thirty-six (36) feet high: (Chap 3.2, Grp 2, Art 2. Sec341, Title8,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): 'C.A.C.) ` .
❑ Las owner of the property, or. my employees with wages.as their sole compensation, will do the work, and the O As owner -builder; I wilt 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, finless such person has a permit to do such work from that division.
Law does not applyto an owner of property who builds, or improves thereon, and who does such work himself or r •.
through his own employees, provided that such improvements are not intended or offered for sale: If, however; the 11 Division of IDdustriaf Safety Permit No.
building or improvemnt is sold within one year of completion, the owner -builder will have the burden of proving that Date. Applicant
, he did not build or improve for the purpose of sale.). • i
4,11 CONSTRUCTION LENDING AGENCY: I hereby affirm that there 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. s.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.). n.. Lender's Address
❑ 1 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 a - 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.). ' .
t / Signature of Applicant or Agent Date
Policy No. �°-� f✓ Company
.. CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
,Certified copy is,hereby furnished. ;w . the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
OCertifiedcopyis filed with the City Building Inspection Department 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 l have applied for this permit for,the purpose of making inspections.
• Date Applicant
,Signature yoff,Applicant or Agent Date '
Print Applicant/Agent Name
APPLICANT NAME (l. F. MQ Al •-•
i1.f••a
Y�•
ADDRESS ••
255 North E1 Ciel o
CITY/COMMUNITY/STATE/ZIP '
Palm Springs, Ca 92262
JOB SITE ADORESS/SPACE
53-686 Avenida cmudVelasc
CITY/COMMUNITY/STATE/ZIP .
la. Qt=ta, CA 92253
BOK
PAG
PRC C
TWN'
RNG-
SE
S
TRACT -
0.12
LOT
92.50
MOD
SB
..
TRACT NAME -. ..
None
OWNER NAME (L. F. Mq.
Jack-Hoffinam sGu
CONTRACTOR -FIRM NAME
Allan Ra (-o o.
ADDRESS
above '
CITY/COMMUNITY/STATE/ZIP ,,,oveM,
abi
PHONE • '
324-1112
+ LICNC 0
14
1i911 V:?)
ARC/ENG FIRM NAME ,N•,
ADDRESS �•
CITY/COMMUNITY/STATE/ZIP
PHONE M
LICNC II
`
USE OF PERMIT .
Pawl and sm
BL
ZON FSB
SSB
SSB
,RSB
OFC
ZONE ORD I
LOT SZ
END.
SIDE
S'1�
APPL/PRMT _
fliflnq88'
DATE
10-2-84 1 CCM3 -
na=t to wnatr ct a 16x35 cfaol
arxi a 7x7 qna as nert
ammmed
1ol.al>nls
F_.Mech. ,Fee
9.00
Plan Check •Fee
0.12
Const. Fee
92.50
Elect. Fee
5.00 ,
SAff Fee
.81
Plurdbina Fee _ _
8.00
175.43
14
1i911 V:?)
_Ji Ila
.
TOTAL
FEE
BLDG. DEPT.
t . .
VALUATION U Boo .Oo •
��
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
9y
35 Furnace. CorrilSart: .�
3
Steel
w.
$6" :. Inlets & Oulleis
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
U
Y
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick al
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/I.
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32Final