0201 (BLCK)APPLICANT NAME (L. F, MI) /j
;q 12 I SCAtC� . A, lla 41'Jl
� 'I4 • A
•
I' PERMIT APPLICATION •1. IN� ���v
•
'' _ �,(x'^'(M//)'4J` � t
r City of
La Ouinta .t
• �" Department of Building and Safety y• + - 'f '
PAG
PRC
This permit becomes void if work not commenced within 180 days from date of
issuance, OR, it work ,has been suspended or abandoned for a period of 180 days.: • • .'
TWN
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPEN&JION 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 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 anymannerso as :a become subject lathe Workers' Compensation Laws of
and effect. :.
California., +
License Class Lic. Number. ° .
Date Applicant
Date Contractor
NOTICE TO APPLICANT: If, after making this Certificated Exemption, you should become subject to the Workers' ~
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the 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 CERTIFICATION: _. d
such permit to file a signed statement thatheis licensed pursuant to the provisions of the Contractor's License Law
❑1herebycertifythatnoexcavationfive(5)ormorefeet I 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 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 or dismantling thereof, will be more than thirl< six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341, Title B, '
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
C.A.C.)
O I. as owner of'the properly, of my employees with wages as their sole compensation, will do the work, and the.
17 As owner -builder, I will not employ anyone to do work which would require a permit from the Division o1
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 1.3s 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. If, however, the
❑ Division of Industrial Safety Permit No.
building orimprovemntissold within one year ofcompletion, the owner -builder will have the burden of proving that
DateApplicant f ^ .:•.
he did not build or improve for the purpose of sale.).
CONSTRUCTION LENDING AGENCY: 1 hereby affirm that t sere 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 contractogs)_licensed pursuant to the
Contractor's License Law.).:
Lender's Address
OPI am exempt under Sec. V& P.C�1(Atlached Certificate).
I certify that I have read this application and state that tl a above information is correct. I agree to comply with all _
�I�T-)
Date �� 7 ' Owner K �7 -• •,M �� +w oT •.
city and county ordinances and state laws relating to bu Iding construction, and hereby authorize representatives -�-,
1 y— w'
of this county to enter upon the above -'mentioned property for inspection purposes.
PE
WORKERS' COMPENSATION DECLARATION: I 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. Q.
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
❑ Certified copy is hereby furnished.
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling ,
17 Certified copy is filed with the City Building Inspection Department 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 l have applied for this permit for the purpose of making inspections.
Signature of Applicant or Agent Date ;
Print Applicant/Agent Name i
APPLICANT NAME (L. F, MI) /j
;q 12 I SCAtC� . A, lla 41'Jl
ADDRESS
CITY/COMMUNITY/STATE/ZIPg
JOB SITE AOORESS/SPACE
CITY/COMMUNITY/STATE/ZIP
BOK
PAG
PRC
I C
I
TWN
RNGSE
S
TRACT
LOT
MOD
SB
TRACT NAME
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME '
P.�P.�J✓?.�' J' " .e�fir l r�i�.o
ADDRESS
CITY/COMMUNITY/STATE/ZIP i
PHONE a
- k� ,•�..
LICNC M_
ARC/ENG FIRM NAME
ADDRESS - gg
CITY/COMMUNITY/STATE/ZIP -
PHONE N
LICNC It
USE OF PERMIT
BL-
ZON
•FSB..
SSB
SSB
RSB
.OFC
ZONE ORD •
. LOT SZ
END -
SIDE
Arrow Printing 250/1-83
N
„-White: Finance Canary: Assessor
APPL/PRMT •ya�. %D ��i DATE
N .., 'EJ tf .7Z.i�/��i/
�/,�� .: �� :� l 1� ;� � �'�'• ,Orn, •,.•-r t�
I J
4 �L ! �c'i �Ot �` c . �y . 5 `'.��1 �. w aoq Cl�.f-j //ea, .
J
city o
• s r
261983
un
a .�•
TOTAL-
") ' FEE
- k� ,•�..
r a z v _
�• `� •.r -VALUATION " Gulp,+!/ i �✓* '
Pink Appltcant� •Tag: 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.
❑
NADDITIONAL INFORMATION
O.
N O. (�
7117 d ��/4
/
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath`/i/2
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 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