0691 (PLBG)' PERMIT APPLICATION 551
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City of La
Ouinta t,
Department of Building
and Safety
BOK
PAG 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.
• • I • ' • . ' C.
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need hot be completed if . -
' LICENSED CONTRACTORS DECLARATION:. I hereby affirm that I am licensed under provisions of Chapter -9:
the permit is for one hundred -($100) o• less:.) certify that in the performance of the.work for which this permit is
' (commencing with Section 7000) of Division 3ef 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'Compensatioh Laws of
and effect. ////,j/!-
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California. '
License Class Lic. Number l%r?
Date Applicant
' Date - .Co tr or �' / -�� r . ^.._. '.NOTICE TO APPLICANT: If,'after making this Certificati of Exemption, you should become subject to the Workers'
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OWNER -BUILDER DECLI••I herebaffirm that I am exempt from the Contractor's License Law for'the - •..�
ARATON: y
' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall
..: ,
;be deemed revoked.
following reason (Sec.' 1.5 Busnessand Professions Code: Any city or county which requires a permit to ..
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construct, alter, improve. demolish, or repair any structure. prior to its issuance, also requires the applicant for
DIVISION -OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: . '.
such,permittofileasignedstate inente, at he is licensed pursuant totheprovisions ofthe Contractor'sLicense Law , '
C. 01 hereby Certify that no excavationfive(5)ormorefeetihdepthintowhichapersonisrequiredtodescend,wilibe
' (Chapter 9(commencing withsect ioA 7000)of Division 3 of the Business and Professions Code)or that he is exempt','
made in connection with work authorized by this permit• and that no building structure, scaffolding; falsework, or-
`.,.theretrom and the basis for'the.alleged exemption. Any violation of*Section 7031.5 by -any applicant for a permit • °•'
demolition or dismantling'thereif, will be more than thirty-six (36) feet high: (Chap 3.2, Grp 2, Art -2, Se041, Title B,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): aR':•. a
C.A.C.)
0 1, as owner of the property, or my employees with wages as their sole compensation, will do the work; and the ' ',
0 As owner -builder, 1 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
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,through his own employees, provided that such improvements are not intended or -offered for sale. lf, however, the
C3. Division, of Industrial 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 1.did not build or improve for the purpose of sale.).', . ;,; ? .CONSTRUCTION
LENDING AGENCY: I hereby affirm that,there is a construction lending agency for the performance
.0 I, as owner of the property,.amexculsively contracting with licensed contractors to construct the project (Sec: -
of the work for whichthispermit 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
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Contractor's License Law.).
Lender's Address
0 l 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.] agree to,comply with all
Date Owne7
city and county ordinances and state laws relating to building construction, and hereby authorize representatives '
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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, ora
' certificate of Workers' Compensation Insurance ,`or a'certified copy'thereof (Sec.'3800. Lab. C.):
;
Signature of Applicant or Agent' Date
Policy,No. Company
'CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I'certify I have read this application and 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 to buidling
0 Certified copy is 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 I' have applied for this permit for the purpose of making inspections.
Date Applicant
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPL/PRMT DATE
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ADDRESS-
CITY/COMMUNITY/STATE/ZIP
C( ,ICC G_, ',- ,--
`JOB
JOBSITE ADORESS/SPACE
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CITY/COMMUNITY/STATE/ZIP
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PAG PAG -
PRC
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TRACT
LOT.
MOD
SB
304
TRACT NAME
OWNER NAME (L. F. MI)
to �,..
CONTRACTOR -FIRM NAME '
ADDRESS2.
CITY/COMMUNITY/STATE/ZIP '
PHONE •
5-1 (�_- sS
UCNC P
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ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE • -
UCNC •
•• : •.
USE OF PERMIT
BL
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FSB
SSB
SSB
RSB
OFC .
ZONE ORD N
LOT SZ
-
END
.SIDE
Print Applicant/Agent Name
APPL/PRMT DATE
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1 /` 3/
low 41,q
304
city,ot. La wo ta
TOTAL
FEE
/ OO
VALUATION >/"� ��/• �0
BLDG. DEPT. •
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION DATE i SPECTOR
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.
❑
NO
ADDITIONAL INFORMATION
•��/ 7 a 7 / / I
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
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
PI PyI
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
THIS APPROVAL GRANTED BY THE
DEPARTMENT OF PUBLIC HEALTH Approval of these plans by, the Depangment of iu6W Y
.-�.
IS VALID'. -FOR' Ow_E`�/.l` YEAR ealth of Riverside County does not relieve.the-
FROM D ATE (��'P 1 / er or Architect of the 1'espansibility far the.Eri� n• ?r
PRO /4,L ,r
�y(s nr �1rrliitprt+irai �iaciirn '. .
41
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DIVISION OF: ENVIRONMEM.TAP_ AAEALtliil,
Feed-Estabiishment. X � Disp a
♦Trailer Park ?
. �X_L.S.L GeL:Sepfic.Tank
Motel, Apr -Hotel- Sq. F ' pf Leach Line
-Dwelling(("S—> ADD 1 Y J
x Seepage Pit°u J
Commercial Building /WX'• t Connection to. Sewer �YCe.✓✓• EXisr. �°�T� !/
Swimming. Pool.;
/—_ No' on-site regenerating water softening- devices may the discharged into the individual sewage dispos.. F:♦ +
system . herewithr approved without clearance from the -r Quality Control Board. r
er Supp y ser% Ts ins�al ait must_" a rom 'an approve source.
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All sewage dispos'�nstaiiation must conform with requirements "of ,current ,Uniform Plumbing Code. '
Any Cutting, gradin or :.fillip in excess of four 41 feet. will null" s -y-wg dispD.saLapprovaL
pproval has .been` obtained from the Regional Water `Quality Control Board for installation. of the sew•.
`age disposal system.. ,
`--�1Sis'tS to c�rti iii�at—fhe" versidZounty . epar�t of -Pub is Health'appr ves for' :cons'tructior,,,
oP installation the items) checked above.
Date — —�6 ' , By _