001297 (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.aband=-ned for a period of 180 days.
-7... " - ..
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE:,•This section need not be completed if
' 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 (3rtify that in the performance of the work for which this permit is 1
'(commencing. with Section 7000) olZvision 3 of the Business and Professions Code, and my license is in full force
issued, I shall not employ any person inany ma merso:asto become subject9othe Workers' Compensation Laws of
and effect.
California.
• License Class Lic.-Number'
Date Applicant
,-Date Contractor T • .• *^ ° ''•
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'-.
OWNER=BUILDER DECLARATION: I hereby at firm that I am exempt from'. -.the Contractor's License* Law for the
. -Compensation provisions of the Labor Code, y+u must forthwith comply with such provisions or this permit shall'
following'reason-_(Sec. 7031.5: Business and Professions Code: Any city or county whichrequires.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 CEFTIFICATION: .
such permit to file a signed.statementthatheislicensedpursuanttotheprovisionsoftheContractorEsLicenseLaw
01hereby certify thatnoexcavationfive(5)or,nord,feetindepth into which a person is required todescend,willbe
(Chapter 9 (commencing with section 7000) o1 Division 3 of the Business and Professions Code) or that he is exempt ',.
made in connection with work authorized by ttts 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 for a' permit
. • demolition of dismantling thereof, will be more han thirty-six (36) feethigh. (Chap 3.2, Grp 2, Art 2, Sec341 jitlea,
subjects the applicant to a civil penalty of not more than five;hundred dollars ($500.): -
CAC.),
r ❑ I. as owner of the property, or. my employees with wages as their sole compensation, will clothe work, and the
❑'As owner -builder, I will not employ anyorre'to do work which would require a permit from the Division of
structure is. not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Industrial Safety; as noted above, unless suet' person has a'permit to do such work from that division.
Law does not apply to an owner of property who builds. or improves thereon, and who does such work himself or
❑ Division ot. Industrial Safety Permit No. -
through his own employees, provided that such improvements are not intended or offered for sale. If, however, the
building or improvemntis sold within on eyear of completion. the owner:builder will have the burden of proving that
Date Appl;ant -
he did not build or improve for the purpose of sale).
CONSTRUCTION LENDING AGENCY: I hereby afirm that there is a construction lending agency for the performance
• O I, as owner of the property: am exculsively contracting with licensed contractors to construct the project (Sec: .
of the work for which this permit -is issued (Sec. 3097; Civ. C:).
7044. Business and Professions Code:'The Contractor's License Law does not apply to an owner of property who,
Lender's Name
builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant.to the '
>-ZONE ORD.. '�•,•
Contractor's License Law.).,I- . II
Lender's Address
/ O i am exempt under Seca B: '$ P.C. (Attached Certificate).
I certify that I have read this application and sate that the above information is correct. l agree to comply.with all
"Date Owner' f—z— " ��� Ff �"
city and county ordinances and state laws relal ing to building construction, and hereby authorize representatives
46 — \
of this county to enter upon the above=mentiL-led property for inspection purposes.
•' WORKERS' COMPENSATION DECLARATIONI hereby affirm that I have a certificateof consent to self -insure; or a -'
- -
certificate ot,Workers° Compensation.lnsurance ,or a certified'copy thereof (Sec. 3800. Lab: C.)..:
r'
Signature of Applicanfor Agert Date
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHOR17A TION OF ENTRY: I certify l have read Misapplication and state that
O Certified copy is:hereby furnished i • - •i:
the information given is correct. I agree to conplywilh all state laws and county ordinances relating to buidling
' -n Certified copy is•tiled with the City Building inspection Department or City Department.. "
.. construction,'and authorize a'representative if the City of Li Quinta 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 Aged Date
Print Applicant/Agent Name
APPLICANT NAME'(L, F. MI) Justin 1.§dth -
ADDRESS 53-670 Avenida Villa -
CITY/COMMUNITY/STATE/ZIPLa Quinta'- CA 92253 -
o
JOB SITE AOORESS/SPACE
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CITY/COMMUNITY/STATE/ZIP '
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PAG-
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FIND
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TRACT
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TRACT NAME
OWNER NAME (L. F. MI) Applicant
CONTRACTOR -FIRM NAME .,. - ,
applicant .<
ADDRESS ab
,,�M
above
CITY/COMMUNITY/STATE/ZIP
above-'
PHONE .
LICNC
,ARC/ENG FIRM NAME -•
ADDRESS
CITY/COMMUNITY/STATE/ZIP ••
PHONE .
LICNC M
USE OF PERMIT Y'� Fence
Y
BL
ZON
FSB
.•+ SSB
SSB
RSB
>-ZONE ORD.. '�•,•
,LOT SZ-'
END
.. SIDE-
APPUPRMT [ B 'J l i ��A•'fi �H5 J3/M.
Pe m t to construct appro= 1$' Zln. ft.
of 6' high wood fence as per appooved pians.
Permit Rm-e 20.03
TOTAL': 20.00
FEE
,A0438
BLDG. DEPT: VALUATION ]53.00
•
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
Steen
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.
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 E (3!1/e
PLUMBING APPROVALS
15 Ground Plumb
16 ater 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
296 Bonding
30 Fixtures
31 Service
32 Final