001030 (SIGN)PERMIT APPLICATION
City of to Duinta
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 orabandoned for a period of 180 days
b t' n
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completd if
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions. of Chapter -9
the permit is for.one hundred ($100) It. less. I certify that in the performance of the work for which this permit is -
(commencing with Section 7000) of Oivisiod3 of the Business and Professions Code, and my license is in full force ..,
issued, [shall not employany person in any manner so asto become subject to the Workers'Compensation Law: of '
and effect.
California. r
License Class Lic. Number
Date Applicant
Date" Contractor .... •
. `NOTICE TO;APPLICANT: If, after making this Certificate of Exemption,•you should become subject to the Work,rs'
ra.
OWNER -BUILDER DECLARATION: I herebyaffirm that I am exempt from the Contractor's License Law for the
Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit st all
following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to
be 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 -permit to file a signed statement thathe is licensed pursuant to the provisions of the Contra ' ctor'sLicense ' Law
0lherebycertifythatnoexcavationfive(5)ormorefeetindepthintowhichapersonisrequiredtodescend,willbe
(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 exemption. Any violation of Section 7031.5 by any applicant fora permit _
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2. Sec341, TitIE8.
subjects the applicant to a civil penalty,of not more than five hundred dollars ($500.): r cr l .
C.A.C.)
' 0 I, as owner of.the property, or my employees with wages as their sole compensation, will do.the.work; and the
0 As owner -builder, I will not employ anyone to do work which would require a permit -from the Divisior 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 himselfor
CITY/COMMUNITY/STATE/ZIP
c :through his own employees: provided that such improvements are not intended or offered for sale. If, however, the
'I ' Id 'th' f I Y th b 'Id 'llh th b d f 'n th t
O, Division of Industrial Safety Permit No.
^-•- •--'---•
urdmgorlmprovemn Is so wI tone year o comp elon. eowner- w erwl . ave a ur e o prove g a
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'contracts for such projects with a contractor(s) licensed pursuant to the
Contractor's License Law.).
0 1 am exempt under Sec. • !f2• B. 8 P.C. (Attached Certificate).
Date
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent. to self -insure, or a
• certificate of Workers' Compensation Insurance•, ora certified copy thereof (Sec. 3800. Lab. Q. -
Policy No. Company
0 Certified copy is hereby furnished.
O Certified copy is filed with the City Building Inspection Department or City Department....
Date Applicant
APPLICANT -NAME (L: F. MI) TN ^ •
tL ifaGi
ADDRESS .
77-995 Tampiw
CITY/COMMUNITY/STATE/ZIP
Ta nninta ^ CA, 92253
JOB SITE ADDRESS/SPACE ,
77-995 Vico Suite B
CITY/COMMUNITY/STATE/ZIP
La Quinta CA 92253
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TRACT NAME -
OWNER NAME (L. F. MI) 77����-''�
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CONTRACTOR -FIRM NAME � S��� .•y ,
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ADDRESS _ -
above
CITY/COMMUNITY/STATE/ZIP
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�4F ]IANC
PHONE 0
LICNC II
ARC/ENG FIRM NAME '
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE M
TOTAL '•'
FEE
LICNC ♦
'
USE OF PERMIT Sign
BL
ZON
FSB-
SSB
SSB-
RSB
OFC
ZONE ORD •.
LOT SZ
'END
SIDE
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency fdr the performance
of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
certify that I have read this application and state that the above information is correct. l agree to comply will, all
city and county ordinances and state laws relating to building construction, and hereby authorize.representati/es
of•this county to enter upon the above=mentioned property for inspection purposes. '
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I'certify I have read this application and state -hat
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
construction, and authorize a'representative of the City. of La Duinta Department of Building and Safety to a der
upon the property for which I have applied for this permit for the purpose ot•makirlg inspections.
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMT a
1Dr>,-E30-84J SOW Sign
Permit to install 4
x 5 sign as per
.. amroVed phms.
Plan Cock Fee
6.50
Const. F�
10.00
SMI Fee
5.0
TOTAL '•'
FEE
��8,
BLDG. DEPT.
VALUATION 589100
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
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.
❑
NPON
ADDITIONAL INFORMATION
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
Value.
7A Walls (Batts)
126 Ceiling (Batts)
12C7 Ceiling (Blown)
14 Final
PLUMBING APPROVALS
15 Ground Plumb
16 WateP Piping
17 Rough Plumb
18 Vents
19 Sewage Disposal
20 Sewer
21 Water Heater
22 Water Softener
23 Water Service
24 Gas Test y
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-