0690 (RER)PERMIT APPLICATION
0"
City
of La Ouinta
Department of Building and Safety ,
CITY/COMMUNITY/STATE/ZIP -- -
414
BOK
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.
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CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed.if
LICENSEDCONTRACTORS DECLARATION: I hereby affirm that,l am licensed under provisions of Chapter'9...
the permit is for one hundred ($100) o, less. I cerify that in the performance of.the work for which this permit is
" (commencing with Section 7000)ofDivision •3of.theBusiness andProIssionsCode ,andmylicense isin:lullforce
issued, I shall not employ any person in any mann:r so as to become subject to the Workers'Compensation Laws of
and effect. .lf �j/
California.
^
License Class f ��eKNumbei , %
Date Applica.t .
Date �! �' J Contractor) �At
INOTICE TO APPLICANT: If, after making, this Cert iicate of. Exemption, you should become;subject to the Workers'
OWNER=BUILDER DECLARATION: I hereby affirm that I am exempt Irom She Contractor's License Law 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 CERTI °KATION:
such permit to file a signed statement thathe is licensed pursuant to the provisions of the Contractor's License Law:..
0 1 hereby certify that no excavation five (5) or mere feet in depth into which 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 aermit, and that no buildingstructure. scaffoldingJalsework, or
therefrom and the. basis for the alleged exemption. Any .violation of -Section 7031.5 by any applicant for a permit,
demolition or dismantling thereof, will be more th.en 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,:fivetlundred dollars, ($500.):
C.A.C.)
O I, as owner of the property, or my employees with wages as their sole compensalion, will do the work, and the..
O As owner -builder, I will not employ anyone -D-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
r
O Division Industrial Safety Permit No.
through his own employees: provided that such improvements are not intended or offered for sale. If, however, the
of
• building or improvemnt is sold within one year of completion, the owner -builder will have the burdenofproving that
Date Applicant
he did not build or improve for the purpose of sale.).
CONSTRUCTION LENDING AGENCY: I hereby affirn that there is a construction lending, agency for the performance .
O 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 3D97. Civ:.C.). .
7044. Business and Professions Cade: 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
- -
coniraclor's License Law.). _
Lender's Address
O 1 am exempt under Sec. B. 8 P.C. (Attached Certificate). -
I certify that I have read this application and stat! that.the above information is correct. I agree to comply with all ....
Date Owner'
city and county ordinances and state laws relatir3 to building construction, and hereby authorize representatives .
of this county to enter upon the above-mentiond property for,inspection purposes,
WORKERS' COMPENSATION DECLARATION: •1 hereby affirm that I have a certificate 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-60MPLIANCE AND AUTHORIZATON OF ENTRY: I certify l have read this application and state that '
O Certified copy is hereby, furnished.
the information given is correct. I agree to compry.with all state laws and county ordinances relating to buidling
O Cer-ilied copy is filed with the City Building Inspection Department or City.Department:.:
construction, and,authorize a representative of he City -of La Ouinta,Department of Building and Safety to enter•
upoA the property for which I have applied for his permit for the purpose of making inspections.
Date Applicant
Signature of Applicant or Agent Date
APPLICANT NAME
N.A�MM�E (L•.F: MSI)
ADDRESS '
CITY/CO MUNITY/STATE/ZIP '
A., k t ..S
JOB SITE ADDRESS/SPACE - -
va s �//c4A
CITY/COMMUNITY/STATE/ZIP -- -
414
BOK
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Se, •
TRACT NAME
OWNER NAME (L. F: MI) -
CONTRACTOR -FIRM NAME ,
ADDRESS
CITY/COMMUNITY/STATE/ZIP
P"aLICN-°'6��
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP -.
PHONE. 11
LICNC N
'
USE OF PERMIT
BL
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1
FSB
SSB
SSB
RSB
OFC.
ZONE ORD N . . •
LOT SZ
END
SIDE
Print Applicant/Agent Name
APPL/PRMT DATE
K rr g q J /4 I1 " G .
PXz;C,il 17- 7-0 �•= N ��� ..? / �,�G �vi��+
f�c,�.cl �.f`'• i E� � 7 5��
MAY. 3 1984
City of La Quiiita ,
y '
FEE
VALUATION ,��'UU
BLDG. DEP'.
NO.
OPERATION DATE INSPECTOR
NO.
OPERATION `DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
34
Plenums & Ducts �f
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.
❑
NPON
ADDITIONAL INFORMATION
✓✓✓ 6
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath 5 /
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 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