001050 (RR)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 abandoned for a -period of 180 days. -
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed it
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 theBusiness and Professions Code, and my license is in full force issued. I shall not employ any person in any mannerso as to become subject to the Workers'Compensation Laws of
and effect. I "I _ / ; California.
NLicense Class / Lic. Number r
ate Contractor ' '/ ..�.. t _. t —' /•! Cin kv
f . .
OWNER -BUILDER DECLARATION: I hereby affirm that I am 6empt'tro1111 the Contractor's License Law for the
following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, alter. improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for .
such.permit to file a signed statement -that he is licensed pursuant to the provisions of the Contractor's License Law
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code)or that he is exempt
therefrom and the basis for the alleged exemption. Any violation -of -,Section 7031.5 by anyapplicantfor a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
O I. as owner o1 the property, or my employees with wages as their sole compensation, will do the work, and the • .
structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License
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 safe. If, however, the
building or i mprovemnt is sold within one year of completion, the owner -builder will have the burden of proving that
he did not build or improve for the purpose of sale.).
O I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec.
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'contractor(s) licensed pursuant to the
Contractor's License Law.):
O 1 am exempt under Sec.' B: 8 P.C. (Attached Certificate)..,
DateOwner
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.)...
Policy No. Company
O Certified copy is hereby furnished.
O Ceriified copy is filed with the City Building Inspection Department or City Department..
Date Applicant
APPLICANT NAME (L, F. MI(
Custm Poofim Comoanv
ADDRESS'
78-550 )bad
CITY/COMMUNITY/STATE/ZIP
Indio. CA 92201
JOB SITE ADDRESS/SPACE ..
52-293 XMKONIM Eisenhower
CITY/COMMUNITY/STATE/ZIP
CA 9225
La CMinta_ 3
BOK /\.. P�
J�
PRCa� 7 C 7WN ,
PINGSSE
S`i'll .50
TRACT
��IW
LOT ^
CJ-{/
MOD •,
SB
TRACT NAME
OWNER NAME (L, F. Tir . �+�•,U,,,��1 T
ALAME_ ►7y.�.,,.„`a 111G�/1f�:
CONTRACTOR -FIRM N • '
l.W)L.>.ALI
ADDRESS +
above
CITY/COMMUNITY/STATE/ZIP -
a
PHONE F t
345-3751
LICNC II
274 921
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE II
LICNC •
,
USE OF PERMIT •r�,..��
BL
ZON
FSB
SSB
SSB'
RSB
OFC
• ZONE ORD . ••
LOT SZ
END
SIDE
Date Applicant
• NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the;Workers' '
Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: .
O 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be
made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341, Title B,
C.A.C.)
O'As owner -builder,.) will not employ anyone to do work which would require a permit from the'Division of
Industrial Safety, as noted above, unless such person has a permit to do such work from that division.
O Division of Industrial Satep Permit No.
Date Applicant
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
of the work:for.which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the above information is correct. I 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 above-mentioned property for inspection purposes.
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: 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, and authorize a'representative of the 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.
• Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPVPRMT not n s o 1DAT
1-14-84 EMG
Pennit to re -roof complete house.
using m%l metal on edges, • 1 layer
30 lb felt, with 2 layers 151b felt,
small crushed rock and mated white.
Permit Fee 38.50
S`i'll .50
��IW
TOTAL'
FEE.
39.00
BLDG. DEPT.
VALUATION 2,100.00
NO.
OPERATION DATE
INSPECTOR
NO. OPERATIONDATE
INSPECTOR.
29A Grounding Wire
BUILDING APPROVALS
29B Bonding
MECHANICAL APPROVALS
30 Fixtures
1
Set Back
32 Final
33 Ventilatiori System,
N
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
1.0A
Fireplace T,O.
❑
ADDITIONAL INFORMATION
NPON
11
12
Exterior Lath
Internal Lath
_
/,2/�
/
12A
Drywall
13
Finish Grade
INSULATION
Thick
lValue
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,
SEWAGE SYSTEM SIZE & LOCATION
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
26
Power Pole
27
Cod t
n u�
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
STREET NAME
�j