0566 (RPL)r
PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
This permit becomes void if work not commenced within,180 days -from -dale of issuance, OR, it work has been suspended or:abandoned f=5r a period of 180 days
APPLI ANlr NAME (L. F. MI(
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. ) certify !hat in 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 any mannersc as to 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 Certificate of 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 mu. -.t 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...
construct, alter, improve, demolish, or repair any structure: prior to its issuance, also requires.the applicant for-
~ ;DIVISION OF INDUSTRIAL SAFETY PERMIT.CERT.IFICA TION:.
.such.permit to file.a sigged s.taterifent-that he1s licensed pursuant to the provisions of the Contractor's License Law
•0A hereby certify that noexcavation five (5)ormore feet in 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 wbrk:authorized.by this pernit, and that 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 ondisirantling thereof; will be more thant.rirty-six (36) feet high: (Chap 3.2; Grp 2, Art 2; Sec 341, Title 8, '
subjects the applicant to a civil penalty of not.more than five hundred' dollars ($500.):
C.A.C.)- a;.4,'
0 I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the _
0 As owner-builder,'I will not employ anyode to db work which would require a permit from the Division of
- 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 pers-n 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
s
through.his own.employees provided that such improvements are not intended or offered for sale. If; however, the
❑ Division__; Industrial Safety Permit No;
building or improvemnt.is sold within one year of completion, the owner -builder will have the burden of proving that • •.
.. Date • Applicant
he d(d,not build or improve for the purpose of sale:). , c t+;
CONSTRUCTION LENDING AGENCY: I hereby affirm flat there is a construction lending agency for the performance
❑ 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. 30+7, Civ. C.). • i
7044. Business and Professions Code: The Contractors License Law does not apply to an owner of property who
A
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
50.1 am exempt under Sec. - B. 8 P.C. (Attached. Certificate).
I certify that Lhave read thisapplication and state that the above information is correct. I agree to comply with all
Date Owner ' ''q
-city and county ordinances and state laws relating Ic building construction, and hereby authorize representatives
LOT SZ
of this county to enter upon the above-mentioned property for inspection purposes.
WORKERS"COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self•insure, or.a
, END'.,
certificate of Workers' Compensation Insurance , or a certified, copy thereof. (Sec. 3800. Lab. Q.
Signature of Applicantor Agent Date
Policy No, Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:.'I certify l have read this application and statethat
0 Certified copy i£ herebyfurnished. -: /�
the information given is correct. I agree to comply vith all state laws and'county,ordinances relating to buidling
a'represeniative of the City of La Ouinta Department Building and Safety to enter
'0 Certified copy Is filed wit the City Building Inspection Depart t or dy Depardm nom.
y 1 / 'Er;' t rte,
construction, and authorize
upon the property for which'I have applied for this permit for the purpose,of making inspections.. '
Date Applicant ��
1
_ _
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPLI ANlr NAME (L. F. MI(
ADDRESS. .. -.. .. .
V -�z
CITY/COMMUNITY/STATE/ZIP "
. ,'�/,07 Z2eser70, 4�ZIL • 9�t
JOB SITE ADDRESSISPACE
y_- / , 0eCITY/C
BOKK(�'(%PAGG^L
C. .
C/y�:.
- ,.
TWN
FIND
SE
S
ITRACT / //� �/
MOD
SB,-
,
TRACT NAME L
OWNER��;;AAME (L? F. MI) _
/`l'IJl1GJ� �I'pi
CONTRACTOR -FIRM NAME 177 { ,. • '
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 0 Q” ,J 5
LLIICNCC..
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE
LICNC 0
.TOTAL
FEE�—
USE OF PERMIT
3 11 1
BL_FJ
ZON
FSB
SSB
SSB
RSB
'OFC.
.ZONE ORD.
LOT SZ
, END'.,
SIDE .
APPL/PRMT. 0 9 9 I�T��
. _ eAr 111111
r �
G'6We,-
of'.1 ec_
n .9—
e,000,,
.TOTAL
FEE�—
VALUATION O��CSCi
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.
❑
NPON ADDITIONAL INFORMATION
7 j
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
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 PiI
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final