PAT (0344)•
r
PERMIT APPLICATION
S. City
'Department
of La Duinta
{ • k of Building and Safety : ..
_
PRC
C
..
,7his.permitbecomes void if work not commenced within 980 days from'dale of issuance, OR, if work has beensuspended or - abandoned for a period of 180 days.. ,
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CERTIFICATE OF. EXEMPTION FROM WORKERS'COMPENSATIONINSURANCE: 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 (5100) o, less. I certify,that in the,performance of the work for which this permit,is .. {
n. (commencing with Section 7000) of Division 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' Compensation Laws of') .
and effect. .. .
California.
License Class Lic. Number
.Date Applicant
'Date - - Contractor
.. . NOJICE.70,APP.LICANT: If, after making,this Certificate!of.Exemption, you should become subject to the Workers'
OWNER=BUILDER DECLARA710Ni thereby affirm that I am exempt from the Contraclor's.License.La'w for the
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Compensation•provisions,,of the Labor Code, you,must forthwith comply with such provisions or this permit shall
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•+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 tofile asigned statemenlthat heislicensed pursuanitothe provisions ofthe Contraclor'sLicense Lav/'
01 hereby certifythainoexcavation five (5)ormore feetindepth into which aperson isrequiredtodescend, 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. exempt ion. Any.violatiorgof Section 7031.5,by any.applicant for a permit .,
demolitioh'or dismantling thereof: will he more than thirty-six (36) feet high. (Chap 3:2, Grp 2, Art 2, Sec341, Title B, -
subjects the applicant to a civil penally of not more,than. five hundred dollars ($500.1: . "! • - .:-
C,At�.�n . , - - - •'• •+
�s�er of theproperty: or my employees with wages. as !heir compensation, will do the work; and the
I do would -from
structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License
O As' owner•builder, will not employ anyone to work which require a permit the Division of .a
:.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 improvements are not intended or offered for sale. If; however, the
_. ', ,^; O Division of In dustrial,Safety Permit No. _
buildingorimprovemntissoldwithinone,yearofcompletion,theowner•builderwillhavetheburdenofprovingthat
Date Applicant •
he,did notbuild or improve for the purpose of sale.). , -- .1
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CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
O L as owner,of the property, am exculsively contracting with licensed contractors -to constructthe 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°r
Lender's.
builds or Improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the
END
Contractor's License Law.)...
Lender's Address
O I 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
✓'Owner/..�.
' - '-.-
•�* 'City and county ordinances and state laws relating to building construction, and hereby authorize representatives
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41161AS, COMPENSATION DECLARATION: I hE� eb affirm thatl have a certificate of consenato self -insure, or a
•; of this county to enter upon the above-mentioned property for inspection purposes..', .•
" certificate of*Workers' Compensation InsuratSce , or a:certified copy thereof.(Sec. 3800: LA.'C.)
Signature of Applicant or Agent Date
Policy No. Company .
CERTIFICATE OF COMPLIANC6AND AUTHORIZATION OF ENTRY: I certify I have read thisapplicationand state that
' O Certified copy is,hereby furnished. 4'
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'Oepartmenror City Department.-,
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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
APPLICANT AME (L; F. MI)
ADDRESS
CITY/COMMUNITY/STA-IE/ZIP .. ,
JOB SITE ADDRESS/SPACE
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7iK
CITY/C UNITY/STATE/ZIP
BOK
PAG
PRC
C
..
TNM
RNG
SE "
S
TRACT
- LOT
I
MOD
S8
.
TRACT NAME .. ^
OWNERpAME (L. F. MI)
CONTRACTOR -FIRM NAME _ ..•
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 0
LICNC 0
ARC/ENG FIRM NAME .. '
ADDRESS -
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC • ••
USE OF PERMIT
81.
ZON
FSB,.
SSB
SSB
RSB
OFC'
• 'ZONE ORD-$' .
LOT'SZ - ,,..
END
- SIDE_ 4.:;
APPVPgMT DATFO
n44
6'Gam' /�
qtyL ,1
,.., ` : s: TOTAL .�
+"± - c FEE
VALUATION
BLDG. DEPT. -
Q
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.
❑
OP'NO. ADDITIONAL INFORMATION
�r. /�/✓ f/X� % /
✓ U /` N
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
PSL P/1
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29. Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final