0621 (BLCK)PERMIT APPLICATION
City of La Ouinta
Department of,Building and Safety
I
^.d-AEs_§93- Avenida Villa
This permit becomes void it work not commenced within.180'days from date of issuance.
OR, if Work has been suspended or abandoned for a period of 180 days. - -
'
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'Certiy that'in the performance of4he work for which this permit is
(commencing with Section 7000) of Division 3 of the Business and:Professions Code, and my license Win full force
issued. I shall not employ any person in any manne, so asto become subject to the Workers'Compensation Laws of .•
and effect.
California. `
License Class Lic. Number
Date Applicant
' Date Contractor
..NOTICE TO APPLICANT: If, after making•this'Certif,•cate'.of Exemption: you should.become subject to the Workers' '-
OWNER -BUILDER DECLARATION: • I hereby"aflirm 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 '.
be deemed revoked.
following reason (Sec. 7031.5.' Business and, Professions Code: Any city or county which requires a permit to,
SB
construct, alter; improve, demolish, or repair any structure, prior to its issuance; also requires the applicant -for...,-
DIVISION OF INDUSTRIAL SAFETY PERMIT.CERTIFCATION:
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law,, •_
b I hereby certify that no excavali - on five (5j or mo!e feet in depth intd Whib a person is required to descend, will be
(Chapter 9(comme9cing.with section 7000) of Division 3 of the Business and,Professions Code) orthat he isexempU
'made in connection with work authorized by this pimii, 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 thirty-six (36j feet high: (Chap 3.2, Grp 2: Art 2; Sec'341, Title B:
subjectsthe applicant to a civil penalty of not more than five hundred dollars ($500.):
C.A.C.)
;0 I, as 0wner,ot the property, or my.employees with wages as their sole,eompensation. will do the work, and the .
0'As owner -builder, I will not -employ anyone t.• do work which would require a permit from the Division of r
• .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
'LICNC
through his own employees• provided that such improvements are not intended or offered for sale. It, however, the
0 Division of.lndustriaLSafety Permit No.
building or improverrint is sold within one year of completion, the owner -builder willhave the burden of proving that -
.' Date Applicait.
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 performance
.0 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
. ' • -
builds or improves thereon, and who contracts for such projects with a contractors licensed pursuant to, the
Lender's Name
Contractor's, License Law.). �— '� '� Q �
��
Lender's Address
' ❑ I am' exempt underiSec. - r ti_ G1� B. & P.C. (Attached Certificate)
I certify that I have read this application and state that the above information is correct. ) agree to comply with all
Date t � N Owner
city and county ordinances and state laws relatin-1 to building construction; and hereby authorize representatives
END
of this county to enter upon'the above=mentionel'property for inspection purposes. '
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'. C:)r'
Signature of Applicant or Agent Date
Policy No. Company
CERTIFICATEOFCOMPLIANCE AND AUTHORIZATIDWOEENTAT I,certitythaveread this application and state that . :.
.0 Certified.copy is hereby furnished: •.
the information given is correct. I'agree to coinpy with all state laws and county ordinances relating to buidling -<
O Certified copy is filed with the City Building Inspection.Depaitment'or City - department.
v
construction,. and authorize a Yepresentative.of he City of La Ouinta,Department of Building and Safety to enter
" upon the property for which I have applied for this permit for the purpose of making inspections.
Date Applicant
Signature of Applicant or Agent Date
-,
Print Applicant/Agent Name
AjPPP. LAIC jN N�AiEZI- ;MI) - • '
^.d-AEs_§93- Avenida Villa
d1_TYY//COJDrMrUNIT1Y//ST�A�TE/Z0 '92253
7&aSITEDADDRESS/S�ACVe
CITY/COMMUNITY/STATE/ZIP'
BOK
PAG .
PRC
C
••
TWN
.RNG
SE.-'
S
TRACT •.
LOT,
MOD
SB
TRACT NAME "
.OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME .-
ADDRESS
CITY/COMMUNITY/STATE/ZIP .. . .
Cm ON9-77L42
LICNC •
ARC/ENG FIRM NAME .
ADDRESS
CITY/COMMUNITY/STATE/ZIP•
'PHONE.0
-
'LICNC
UrE OF PERMI1JaJl ..
BL
ZON
FSB
'SSB
SSB
RSB
OFC
ZONE ORD N
LOT SZ
END
.' SIDE
APPL/PRMT 'ye � .' -2,01 NN -8[ Bldg;. -
FP.gitllt t0 cimstruct l i—ne- Me Ot BJ.00.tC
wa11 •
' h
Q
d
Ury 01 Qahata :
Y
AN• P
TOTAL' $ 19.50
FEE ••
i VALUATION $1,050.00
• BLDG. DEPT.
NO.
OPERATION DATE INSPECTOR
NO.
OPERATION DATE ►NSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
'� 7
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.
❑
DP'N ADDITIONAL INFORMATION
NO.
'
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath.`2"
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
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
290 Bonding
30 Fixtures
31 Service
32 Final
STREET NAME