0596 (BLCK)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 fora period of 180 days.
ADDUSS -
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) of Division 3 of the Business and Professions Code, and my license is in lull 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
Dale Z, Contractor
NOTICE TO APPLICANT: If, after making this Certificate ol, Exemption, you should become subject to the Workers' .
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for the
Compensation provisions of the Labor Code, you musJ.forthwith comply with such provisions or this permit shall
be deemed revoked.
following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to
TOTAL
FEE
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 that he is licensed pursuant to the provisions of the Contractor's License Law
0 thereby Certify that no excavation five (5) or more feet in depth intowhich a person 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 fora permit'
'demolition or dismantling thereof. will be morethan thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341, Title B;
Is
subjects a applicant to a civil penalty of not more than five hundred dollars ($500.):-
C.A.C.)
. I. as 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. 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
CITY/COMMUNITY/STATE/ZIP
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 or improvemnt is sold within on.e-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).
,`7r.. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
0 I as owner of the property, am exculsively 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
SSB
Contractor's License Law.). i
�-
Lender's Address
❑ 1 am exempt under -Sec, B. & P.C. (Attached rtificat
I certify that have read this application and state that the above information is correct.I agree to comply with all
Date/1' �' Owne
city and county ordinances and state laws relating to building construction, and.hereby authorize representatives
11
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 a4
END
certificate'ol Workers' Compensation Insurance., or a certified'copy thereof (Sec. 3800. Lab. C,)-
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
APPLJCANT NAME (L. F. MI( %+y
ADDUSS -
CITY COMMUNITYY/STATE/ZIP
JOB ITE ADDRESSISPACE
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CITY/CGMMUNITY/STATE/ZIP '
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TOTAL
FEE
TRACT NAME -
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CTOR-FIRM NAME
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per
ADDRESS -•.
CITY/COMMUNITY/STATE/ZIP
PHONE #
LICNC •
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ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 11
LICNC I'
-
USE OF P MI
BL
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FSB
SSB
SSB
RSB
OFC
ZONE ORD N -
LOT SZ
END
SIDE ;
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and statethat
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 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. ,
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPI/PRMT q 6
r• r � r
CA 1 E
a
TOTAL
FEE
VALUATION
BLDG. DEPT.
NO.
OPERATION DATE
INSPECTOR
NO. OPERATIONDATE 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 . .
61
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.
❑
NOADDITIONAL INFORMATION
��j//r'�` /� ���/�/ G • /Q�
_
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SEWAGE SYSTEM SIZE & LOCATION,
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick 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
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ELECTRIC APPROVALS
REAR OF.PROP.ERTY LINE
_
p/L P/I
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29BI Bonding
30 Fixtures
31 Service
32 Final
•� r
• 4"y •_
78-105 CALLE ESTADO - LA QUINTA, CALIFORNIA 92253 - (619), 664-2246
April 19, 1991
To Whom It May Concern:
The structure located at 52-192 Avenida Diaz in La Quinta is in a
"B" depth one foot Flood Zone, according to the F.E.M.A. flood map,
panel numbers 060709 0005 A.
Sincerely,
BUI G AN SAFE PARTMENT
�yL1
Tom Hartung
Building and Safety Director
TH:es
LTRTH001
MAILING ADDRESS - P.O. BOX 1504 - LA QUINTA, CALIFORNIA 92253