0332 (RR)PERMIT APPLICATION
City of La Ouinta
Department ofBuilding'and Safety
This permit becomes void if work'not commenced within 190 days from date of issuance-.. OR. i1 work has been suspended orsbandoned for a period of 180 days
builds or improves thereon, and who contracts for such, projects with a contractor(s) licensed pursuard.to the
Contractor's. License Law.).
o I am exempt under Sec. B. 6 P.C. (Attached Certificate).
Date Owner
WORKERS' COMPENSATION DECLARATION: 1 hereby affirm that I have a certificate of consent to self -insure, or a
certiticate of Workers' Compensation Insurance, or a certified copy thereol,(Sear3801): Lab. Q.-
Policy.No. Company
❑ Certified copy is hereby furnished.
O Certified copy is filed with the City Building Inspection Department or City Department.
Date Applicant
APPLICANT NAME'IL', F; MI)A�tt .p p4 no11
"°°REss A y " Ld. fT
CITY/C lA" IP
A16 CA -
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 •(5100) o, less: I certifythat in the, performance ofthe, work :for whichthis permit is -
(commencing with Section 7000) of Division 3 of the Business and.Professions Code, and my license is in full force
issued; I shalt not employ any person In any manner so as to become subject to the Workers'.CompensationLaws of
and effect.
Cic..Number /'9
California.
Date
License Class
Date— / / 9 ��� Contractor
Applicant
NOTICE TO APPLICANT: It, allmr.making,this Certificate of Exemption, you should become subject to the Workers' -
OWNER -BUILDER DECLARATION: I hereby affirm thaPI am exempt from the Contractor's License Law for the
Compensatiomprovistone of the Labor Code, you mustforthwith comply with such provisions or.thls permit shall
be'deemed'revoked.
following reason (Sec. 7031:5,. Business end Professions'Code' Any city or county which requires•a permit to,
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construct, after. improve, demolish, or repair any structure, prior to its issuance, also requires the.applicant for
DIVISION,OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
such permit to file asigned_statementthatheislicensedpursuanttotheprovisionsoftheContractortsLicenseLaw
❑ 1 hereby certify that no excavation fWe (5) or mom feet in depth into which a person is required to descend, will be
' (Chapter9(commencing with section 7000) of Division Sof 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 tor,.the alleged. exemption. Any violation of Section 7031.5 by any applicant for a permit ..
demolition or dismantling themoV, will be more than thirty-slx (35) feet high. (Chap 3 21Grp 2, Art 2 Sec 341, Title8,•a', .
subjects the applicant to a civil penalty of not more than five hundred dollars (W.):
C.A.C.) •
. 0.1 as owner of the property; or my employees with wages as their sole compensation, will do the work, and the
o As owner -builder, I will not employ anyone td do work which would.require.a permit from the Division of ..
structure isnot 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
El Division al Industrial Safety Permit No.
through his own employees, provided that such: improvements are not intended or,offered forsale: If, however, the . ...
,PHONE a
building orimprovemntissoldwithin one year ofcompletion, the owner -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 forthe performance
❑ 1, as owner of the property. am axculsivelycontracting with licensed contractors to construct the projeot(Sec
of the work for which this permit is issued-(Sec.'3007, Civ. C.).,
7044 Business and Professions Code: The Contractor's License Law does noCappty to,an owner of property who
builds or improves thereon, and who contracts for such, projects with a contractor(s) licensed pursuard.to the
Contractor's. License Law.).
o I am exempt under Sec. B. 6 P.C. (Attached Certificate).
Date Owner
WORKERS' COMPENSATION DECLARATION: 1 hereby affirm that I have a certificate of consent to self -insure, or a
certiticate of Workers' Compensation Insurance, or a certified copy thereol,(Sear3801): Lab. Q.-
Policy.No. Company
❑ Certified copy is hereby furnished.
O Certified copy is filed with the City Building Inspection Department or City Department.
Date Applicant
APPLICANT NAME'IL', F; MI)A�tt .p p4 no11
"°°REss A y " Ld. fT
CITY/C lA" IP
A16 CA -
JOB SITE A=
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CITY1COMMUNITY/SYkIrErZIP -"
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TRACT NAME,
OWNERINAME (L. F. MI'7_'J / j ,O A�
CONTRACTOR•FIRM NAME .• . .
ADDRESS
CITY/COeMUNITY/STATE/ZIP
PHONE a
LICNC•e
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ARC/ENO FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP - -
,PHONE a
LICNC.e
USE OF PERMIT
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END
SIDE.
Lender's Address
I certitythat I have read this application and state that the above information is correct. [agree to comply with all
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
of this county to enter upon the abovamemioned property for inspection, purposes.
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY i I certify I have read this application and state that
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
construction; andauthorize a,representative of the City.al La Oointa Department of Building and`Safefy to eider
upon the property for whicli'I have applied for this permit for the purpose ofmaking. inspections.
Signature of Applicant or Agent Date
Print Applicant/Agent Name
AP►L/PRMT DATE
A [Oa/•(
iQ,67 �ooF p , AV `T s vA�Fs
La Q�inta
Coll ty
TOTALFEE
i / V01
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. ❑
NPON
ADDITIONAL INFORMATION
�7/
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SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
128 Ceiling (Batts)
12C Ceiling (Bl.own)
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/
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final