001225 (BLCK)0
PERMIT APPLICATION
City of La Duinta
Department of Building and Safety
This'permit becomes void if work not commenced within 180 days from date of issuance.,08, if'work has been suspended or abandoned for a period of 180'days.
LICENSED CONTRACTORS DECLARATION:A hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in lull force
and effect.
License Class Lic. Number
Date' Contractor-'
OWNER -BUILDER DECLARATION',' I hereby affirm that I am exempt from the Contractor's License law for the
following reason (Sec. 7031.5, Business and.Professions Code; Any city or county which requires a permit to
construct, alter, improve. demolish, or repair any structure, prior to its issuance, also requires lhe'applicant for
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law
(Chapter 9(commencing with section 7001) of Division 3 of the Business and Professions Code)or that fieis exempt
therefrom and the basis for the alleged exemption: Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to!a:civil penalty of not more than five hundred dollars ($500.): .
O- I. as owner of the property. or.my employees with wages as their sole compensation, will do the work, and the
structure -is not intended or offered for sale (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 does such work himself or
through his own employees, provided that such improvements are not intended or offered for sale. If, however, the
building or improvemnt is sold within one year of completion, the owner -builder will have the burden of proving that
he did not build or improve for the purpose of sale.).
O 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.).r—]]i ii _ . . .
O 1 am exempt under Sec. - V! I / j"I� '+- B..&Y-C. (Attached' Certificate).
Date Owner
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate -of consent to self -insure, or a
certificate of Workers' Compensation Insurance , orta'certified copy thereok(Sec. 3810. Lab. C.)..:
Policy No. Company
O Certified copyis hereby furnished. +n'
O,Certified copy is filed with the'City Building Inspection Department or.City Department.
Date Applicant
APPLICANT NAME (L. F. MI) JeffRi'cn�
W
ADDRESS 46-705 Washington
yWQ,shiee7v�rto
CITY/COMMUNITY/STATE/ZIP Ia �ta, CA -92253
JOB SITE AODRESS/SPACE 46-705 Washington St.
'
CITY/COMMUNITY/STATE/ZIP a Quanta; CA - 92253
La
8017
PA564
OSA
C
TWN
RNG '
SE
S
TRACT -
LOT
69
7
14.30
MOD
SS
-
TRACT NAME
OWNER NAME (L. F. MI). Applicant ..
CONTRACTOR -FIRM NAME
ADDRESS above
CITY/COMMUNITY/STATE/ZIP above
PHONE 1r 564`1051 \
LICNC 1
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP '
PHONE /
LICNC N
'
USE OF PERMIT block Wall
BL
ZON
513
FSB
SSB
'SSB
RSB
OFC'
ZONE ORD .• . ';
LOT SZ
TOTAL
FEE
END
SIDE
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATIONINSURANCE: This section need not be completed if
the permit is for one hundred ($100) o, less. I certify that in the performance of the work for which this permit is '
issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of
California.
Date Applicant
NOTICE TO APPLICANT: It, after making this Certificate of Exemption, you should become subject to the Workers'.,
. Compensation provisions of the Labor Code, you,must forthwith comply with.such provisions or this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
O I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be
made in connection with work authorized by this permit, and that no building structure, scaffolding; falsework, or
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, SeC341, Title B,
C.A.C.)
O 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.
O Division of Industrial Safety Permit No.
Date Applicant.. .
CONSTRUCTION LENDING AGENCY: I hereby affirm:ihat there is a construction lending agency for the performance
of the work for which this permit is issued'(Sec. 3D97, -Civ; C.): "
Lender's Name
Lender's Address
I certify that I have read this application and state that the above information incorrect. I agree to comply with all
city and county:ordinances and state laws relating to building construction, and hereby authorize representatives
of this county tit enter upon the above-mentioned property for inspection purposes.
Signature''of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I'certity l have read this application and state that
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
construetion,'anMauthorize a representative of.the City of La•Ouinta Department of Building and Safety to enter
upproperty for which 1'have applied for this permit for the purpose of making inspections.
ythe
/ 'Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPL/PRMT n n 12 2
2OATJE3-1155
BT -DG
Pen)nit to constnac .
50 lin.
feet of
6 ft. high block wallas per approved
Plan geek
14.30
Const.,* Fee
22.00
4
EM Fee
.50
PAID FE
513
TOTAL
FEE
37.00
• VALUATION
I
� • BLDG. DEPT.
R �
e
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION DATE INSPECTOP
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
7 Ventilation System
2
Ftgs & Frms
3 ��
34
Plenums & Ducts
2A ,
Slab Grade
35'
Furnace Compart.-
3
Steel
36
Inlets & Outlets
4
Grout Blocks
(j Z-�
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
a
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
F
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final