0565 (BLCK)'APPLICANT NAME (L. -F, M1) ' • +.
ADDRESS
CITY/COMMUNITY/STATE/ZIP .
JOB SITE ADDRESS/SPACE +
• SAAI E'
CITY/COMMUNITY/STATE/ZIP • - - '
BOK PAG , PRC C.I. TWN RNG SE " S
.TRACT •. COT MOD .' SB -
TRACT NAME' r
OWNER NAME (L. F. MI) - ..
bONTRACTOWFIRM- NAME - - •
ADDRESS' .. . +.
CITY/COMMUNITY/STATE/ZIP • • ,
56 PHONE• LICNCI
y-
ARC/ENG FIRM NAME * - - .+•• •.
ADDRESS '
'CITY/COMMUNITY/STATE/ZIP
PHONE 11 - LICNC-M ..
USE OF PERMIT - -
BL ZON FSB SSB SSB RSB. OFC
'ZONE ORD .' -LOT
APPL/PRMT � � �•�/ 17 DA TE
• ��r�7' ro r�vsv� frrr .�
DZ•i 57 A/ �
- C eA/_S7 R uCT BOY
FEE TOES S r'e3S
`• "•�4 - ., •
VALUATION
BLDG. DEPT.
1 PERMIT APPLICATION
.. r
" City of La Ouinta'
• : Department of Building
and Safety
'This permit becomes'void it work not commenced within 980 days from dale of issuance. OR, if -work has been suspended.or abandoned for period of .180 days: -•
-`': r:•:'• 4 •• '. `•''"
CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATIONINSURANCE: This section need not be completed if
' LICENSED CONTRACTORS DECLARATIONA hereby affirm .that I am'licensed' under provisions of Chapter'9', r
th'e permit'is.for_one hundred ($100) o, less. I certify that in the performance of the work for which this permit is
" (commencing' with Section7000)•ofDivision3oftheBusiriessandProfessionsCode.andmy'licenseisinfullforce ,.'
issued; I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of
and'effect.
California. s
License Class Lic. Numbed r
Date ^ . Applicant
' Date .,..-Contractor -=-•t • -'••>• - n' r
"NOTICE TO APPLICANT: If; after making this Certificate of.Exemption. you should become subject to the Workers'
/
• OWNER -BUILDER DECLARATION::' I hereby aflirm that9 am exempt.from the Contractor's.License kaw for the
. -Compensation 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:. ' -
sychpermitto.fiteasignedstatementthat,heis licensed pursuant to the provisions of the Contractor's License Law'' .:
0 . the . rebyceitify that no excavation five (5) or-m`ore feet in clep6intb Which a person is required fodescend,will be '
(Chapter B(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 thaino building structure, scaffolding;.falsework, or. .
.therefrom and the basis for the alleged exemption. Any. violation of Section 7031:5 by.any,applicarit for'a.permil
demolition ordismantljng thereof, wilfbemore than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art'2, Sec341; Title8:
subjects the applicant to a civil penalty of not more'than five hundred dollars'($500) t r •' ' ,
C.A.C.)' '
,+ 0A. as owner of the property, or my employees with wages as their sole compensation, will do the work, and the .
'p 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,vnless such person has a permit to do such work from that -division.,
et
Law, does not apply'to an owner of property who builds, or improves thereon, and who does such work himself or' _
'n u
through his own employees, provided that such improvements are not intended or otfereddoi:sale: If:however, the -
q Division ot.lndustrial Safety Per No.
building orimprovemntissold within one.yearofcompletion;theowner-builder will 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 perlorrnance .:u -
�� L as owner -of the property, am exculsively,contracting with licensed contractors to construct -the project (Sec.
'' of -the work dor which this permit is issued (Sec..3097, Civ. C:).
A7 , 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 �.
• Contractor's License Law.). ;�
Lender's Address
' OA am exempt under Sec. . - •;B. & P.C. (Attached Certificate). _ ,, •
I certify that l have read this application and state that the above.information is correct. I agree to comply with all,
/�'
Date": Owner t/"✓��� 'r '. i�' '� :=�ie r�, �6r'! +
city and county ordinances'and state laws relating to building construction; and hereby authorize representatives
' - t
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, ora '
certificate'of Workers' Compensation Insurance', or a certifiedcopy thereof (Sec. -3800. Lab. C.) : `,1
Signature of Applicant or Agent . Date i
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I'certifyI have read this application and state that'
'. O Certified copy is hereby furnished.. '
the information given is correct. l.agree to comply with all state laws and county ordinances relating 4o buidlin6
O Certified copy is filed with the City Building Inspection Department or City ' Department.' a`;
construction, and authorize,a'representative otthe City of La Ouinta Department of Building and Safety -to enter •;
upon the property for which I have applied for this permit for thepurpose of making inspections.
_.. Date Applicant
- .
•
Signature of Applicant or Agent Date
Print Applicant/Agent Name.:
'APPLICANT NAME (L. -F, M1) ' • +.
ADDRESS
CITY/COMMUNITY/STATE/ZIP .
JOB SITE ADDRESS/SPACE +
• SAAI E'
CITY/COMMUNITY/STATE/ZIP • - - '
BOK PAG , PRC C.I. TWN RNG SE " S
.TRACT •. COT MOD .' SB -
TRACT NAME' r
OWNER NAME (L. F. MI) - ..
bONTRACTOWFIRM- NAME - - •
ADDRESS' .. . +.
CITY/COMMUNITY/STATE/ZIP • • ,
56 PHONE• LICNCI
y-
ARC/ENG FIRM NAME * - - .+•• •.
ADDRESS '
'CITY/COMMUNITY/STATE/ZIP
PHONE 11 - LICNC-M ..
USE OF PERMIT - -
BL ZON FSB SSB SSB RSB. OFC
'ZONE ORD .' -LOT
APPL/PRMT � � �•�/ 17 DA TE
• ��r�7' ro r�vsv� frrr .�
DZ•i 57 A/ �
- C eA/_S7 R uCT BOY
FEE TOES S r'e3S
`• "•�4 - ., •
VALUATION
BLDG. DEPT.
SZ
�.
• £ND -`
' SIDE ,
'APPLICANT NAME (L. -F, M1) ' • +.
ADDRESS
CITY/COMMUNITY/STATE/ZIP .
JOB SITE ADDRESS/SPACE +
• SAAI E'
CITY/COMMUNITY/STATE/ZIP • - - '
BOK PAG , PRC C.I. TWN RNG SE " S
.TRACT •. COT MOD .' SB -
TRACT NAME' r
OWNER NAME (L. F. MI) - ..
bONTRACTOWFIRM- NAME - - •
ADDRESS' .. . +.
CITY/COMMUNITY/STATE/ZIP • • ,
56 PHONE• LICNCI
y-
ARC/ENG FIRM NAME * - - .+•• •.
ADDRESS '
'CITY/COMMUNITY/STATE/ZIP
PHONE 11 - LICNC-M ..
USE OF PERMIT - -
BL ZON FSB SSB SSB RSB. OFC
'ZONE ORD .' -LOT
APPL/PRMT � � �•�/ 17 DA TE
• ��r�7' ro r�vsv� frrr .�
DZ•i 57 A/ �
- C eA/_S7 R uCT BOY
FEE TOES S r'e3S
`• "•�4 - ., •
VALUATION
BLDG. DEPT.
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. ❑
NON ADDITIONAL INFORMATION
31 r
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath 't
t2 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/I
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final