0611 (RPL)APPL_ICANTi NAMI IkF-.�' I C% S A z ,mss
1 ,
PERMIT APPLICATION r.
City of La
Ouinta
Department of Building and Safety
PACO
PRC
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'
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CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
LICENSED CONTRACTORS DECLARATION: 1 hereby affirm that I am licensed under provisions .of'Chapter 9 '•
the permitisfor one hundred ($100).o, less:) certify that in the performance of.the work for which this permitis .
(commencing with Section 7000) of Division Sof the Business 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.
California. '
License Class Lic..Number
DateApplicant
DateContractor k'
NOTICE TO APPLICANT: If, after making this Certificatesof Exemption, you should become subject to -the Workers'
c.
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from'the'Contractor's License Law forthe
Compensation provisions of the.Labor Code, you must orthwith 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 CERTIFICAT ON:
such permit to filera signed s tatement that he.is licensed pursuant to the provisions ofthiContractor'sLicense.Law.. :.101
hereby ceitifythat noexcavation five (5)ormorefee:indepth into which aperson isrequired todescend, will be
-,(Chapter 9(commencing.with section 7000) of Division 3 of the Business and Professions Code) orthat he is exempt
"made in connection with work authoriied by this permi-,-and that no building structure• scaffolding, falsework,-or -
therefrom and the basis for the alleged exemption. Any violation of Section 71131.5 byany applicant fora permit,
demolition or dismantling thereof, will be more than thiry-six (36) feet highs (Chap 3.2• Grp 2 Art 2, Sec 341.Titlefl. -
' subjects the applicant to a civil penalty of notmore than five hundred dollars ($500:):} •:%
C.A.C.) - '
0J. -as owner ofthe property, or my employees with wages as their sole compensation, will do the work, and the • ; '
= 0 As owner -builder,' I will'notemploy anyone to do vork which w6uld require a permit from the Division of
structure is.notintended or offered forsale (Sec. 7044, Business and Professions -Code: The Contractor's License •
fndustrial'Safely, as noted above, unless such person -Stas 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. II, however, the
0 Division of Industrial Safety Permit No.
.building or improvemnt is sold within one.year of completion. the owner-builder.will havetheburclenof provingthat
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 for the performancef? • '
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
Lender's Name
builds or.improves thereon, and who contracts for such projects with•a contractor(s) licensed pursuant to the
' Contractor's License Law.).. ...
Lender's Address
0.1 am exempt under Sec:'' "B: 8 P:C. (Attached Certificate).
I certify that I have read.this application and state that the above information is correct. I agree to comply with all '
Dat,'p Owner
city and county ordinances and state laws relating to b.,ilding construction, and hereby authorize representatives
-
'of this county to enter upon the above-mentioned proierty focinspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, ora
' certificate bf, Workers' Compensation Insurance°:'or a certified copy thereof,(Sec.3800. Lab. C.).,
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
• 0 Certified copy is. hereby, furnished.. ,- A
the information given is correct. I agree to comply with, all state laws and county ordinances relating to'buidling
• 0 Certified copy is'fileIf with the City Building Inspection,DepartmentorCny + ' -- Department
construction; and authorize a' representative of the City of La Ouinta Department of Building. and Safety to enter
1 /,•/ 1r
l •
I,P06-thepropertyfor which I have applied for.this permit for the"purpose of making inspections:
Date! i/IIP Applicant
Signature of Applicant or Agent Date
APPL_ICANTi NAMI IkF-.�' I C% S A z ,mss
ADDRESS
CI TY/C`OMGM.% ,f/STnZIIP,�'�/
CIT:/COMM UNITY/STATE/ZIP
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PACO
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jTRACSIT%6 ;''
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MOD
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TRACT NAME - '• .,
OWNER NAME (L, F. MI)
CONTRACTOR -FIRM NAME -
ADDRESS - -
CITY/COMMUNITY/STATE/ZIP' .. -
PHyOO/N
LL-IICNC 0
ARC/ENG FIRM NAME -
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC •
..
USE OF PERMIT
BL
ZON.
FSB
SSB
SSB
RSB
OFC
,
• ZONE ORO 0
LOT S2
END
SIDE
Print Applicant/Agent Name
APPUPRMT DATE
-%GA;(I Ij� w. '40 2
Ir 39 00
, M
V E ID
MAN � 1984
City oftq - ulAt w
TOTAL
FEE
VALUATION
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.
❑
NON
ADDITIONAL INFORMATION
� • � ,��j/r! ,
F
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath -
12 .Internal Lath -
12A Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
126 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