001140 (BLCK)PERMIT APPLICATION
City of La Ouinta. 6
Department of
Building and Safety
This permit becomes void if work not commenced within 180 days from.dale of issuance. OR, if work has been suspended or abandoned for a period of 180 days.
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CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE:.This section need not 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. l certify that in the performance of the work for which this permit is
(commencing with Section 7000) of Division 3 of the Business and ProfessionsCode, 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. Lic. Number
Date Applicant -
Date Contractor
NOTICE TO APPLICANT: If, after making this Certificate+of. Exemption, you should become subject to the Workers'. .
OWNER -BUILDER DECLARATION: I heieby affirm that •I am exempt from the Contractor's License Law -tor the
Compensation 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
. 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 permitto fileasigned statement that he is licensed pursuant to the provisions of the Contractor's License.Law
01 hereby certify that no excavation five (5) or more feet in depth into which aperson is required to descend, 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 authorized 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
demolition or dismantling thereof, will Ife:more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec 341, Title 8,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
C.A.C.) .,!�W, l • -
•Oti1, as owner of the property, or my employees with wages as their solgcompensation, will do the work, and the
CITY/COMMUNITY/STATE/ZIP
structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License, .
0 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 a permit to do such work from that.division.
Law does not apply to an owner of property who builds; or improves thereon, avid who does such work himself or
through his own employees. provided that.such improvements are not intended or offered for sale. If, however, the
0 Division of Industrial. Safety Permit No.
building orimprovemntissold wilhinone year ofcompletion,the owner -builder will have the burden of proving that
Date Applicant
he did not build or improve for the purpose of sale.).
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency,forthe performance '
0 I, as owner of the property, am exeulsively 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,). \ \ —
Lender's Address
0 1 am exempt under Sec.''-%, . B. & P.C. (AttachedCertificate). ,
I certify that I have read this application and state that the above information is correct. I agree to comply with all
Date r `� 't Owner
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
-
dt 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'certitied copy thereof (Sec. 3800aLab. C.).
Signature of Applicant or Agent Date
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY" 1 certify I have read this application and state that
C1 Certifiedcopy is hereby furnished.
the information given is correct. I agree to comply with all state laws and county ordinances, relating to buidling .
O 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.ttie purpose of making inspections.
Dale / Applicant
Signature of Applicant or -Agent Date
t
APPLICANT NAME (L, F. MI) Jeff,�Cullen
ADDRESS 54--W Avenida Velas co
CITY/COMMUNITY/STATE/ZIP. La Quinta, CA 92253
JOB SITE ADDRESSISPACE -
Above
CITY/COMMUNITY/STATE/ZIP ,
Above
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PIGSIL
ar.
PVC'20
C
Const. Fee
TWIN
RNG
SE
S
TRACT
LOT-
MOD
SB
TRACT NAME
None.
OWNER NAME (L. F. MI) Applicant '
CONTRACTOR -FIRM NAME
Applicant
ADDRESS
Above
CITY/COMMUNITY/STATE/ZIP
Above
PHONE #564-2280 1
1,LICNC'N
ARC/ENG FIRM NAME
ADDRESS _-
CITY/COMMUNITY/STATE/ZIP
PHONE II
LICNC 1
USE OF PERMIT Pre—fab wall
BL
ZON
FSB
SSB
SSB
RSB
OFC'
ZONE ORD 0
LOT SZ
•
END.
SIDE,
Print Applicant/Agent°Name 4
APPUPRMT fl
{ 011 40
1 Z T 17/8 4 _ BLDG.
Permit to install
300' of concrete
6' high wallas per approved plans.
Const. Fee
68.50
SMI Fee
.55
p
DEC
TOTAL
FEE
69-05
BLDG. DEPT.
VALUATION 1 7,500.00
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
SA -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.
❑
OWN
ADDITIONAL INFORMATION
�✓� _ vl 4� �?�/� ��
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
p/L PiI
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final