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0762 (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 for a period of 180 days. ADDRE.�SS/ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if I 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 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. �^ l�License Cr ss Lic. Number C� f J9J California. Date Applicant 57 Dafen f ' /t { Contractor V��� 1(- L1^��r.�► NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' ._, Iens)e Law for the,Compensation OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's Lic 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 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: suchpermittofileasignedstatementthatheislicensedpursuanttotheprovisionsoftheContractor'sLicenseLaw•. 01 hereby certify that no excavation five (5)ormore feet indepth into which apersonisrequired todescend. will be ' j. (Chapter 9(commencing with section 700)) of Division 301 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 Ihe.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, Sec 341, Title 8, ' subjects the applicant to a civil penalty of not more than five hundred dollars (S500.):. .,..,:ii„- 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 Division of structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License: Industrial Safety, asnoted 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 '• through his own employees: provided that such improvements are not intended or offered for sale. IL however, the. .0 Division of Industrial Safety Permit No. building or improvemnt is sold within one year of completion, the owner-builderwill 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 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 FSB Contractor's License. Law.). Lender's Address 0 1 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 Date Owner city and county ordinances and state laws relating to building construction, and hereby authorize representatives ZONE ORD • of this county to enter upon the above-mentioned property for inspection purposes. - r ' WORKERS COMPENSATIONAECLARATION. I hereby aftum that I have a certdlcate of consent to self -insure, or a 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 . O Certified copy 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 Departmient or City Department. construction, and authorize a'representative of the City of La ouinta Department of Building and Safety to enter Date Applicant -'' ' upon the property for which I have applied for this permit for the purpose of making inspections. Signature of Applicant or Agent Date Print Applicant/Agent Name APPLICANT NAME (L. F, MI) ^� - — G. ((J !/Sf/ do ADDRE.�SS/ CITY/COMMUNITY/STATE/ZIP , /7 7A/-5 rC-44- 4717'_11 JOB SITE -%ORESS/SPAC CITY/COMMUNITY/STATE/ZIP BOK PAG - PRC C TWN FIND SE S TRACT LOTMOD -TOTAL,'-: FEE !J' -� Q SB TRACT NAME ° OWNER NAGE (L. FMl).n��� n� CONTRACTOR -FIRM NAME ADDRES�1,r3 CITY/COMMUNITY/STATE/ZIP ' PHONE • ' LICNC M ARC/ENG FIRM NAME• ADDRESS CITY/COMMUNITY/STATE/ZIP - PHONE • LICNC • USE OF PERMIT 8L I -ZON FSB SSB SS8 RSB OFC ZONE ORD • LOT SZ END SIDE APPUPRMT n787. DATE �_J Af:11-,P/% TC (_-'7©.vs71oeuCr /y6 GAI -TOTAL,'-: FEE !J' -� Q VALUATION BLDG. DEPT. NO. OPERATION DATE INSPECTOR 'NO. OPERATION DATE INSPECTOR BUILDING APPROVA'L'S MECHANICAL APPROVALS 1 Set Back 33 Ventilation. System 2. Ftgs & Frrns 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 ` 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.AP.PROVALS: REAR OF PROPERTY LINE.. PSL PSL STREET NAME 26 Power Pole 27 Conduit 28 Service Entrance 29 Wiring . 29A Grounding Wire 29B Bonding 30 Fixtures 31 Service.: 32 Final