000947 (MISC)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 if
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 the permit is for one hundred (S100) o, less. I certify that in the performance of the work for which this permit is
(commencing with Section 7000) of Division 3of the Business and Professions Code, and my license is in lull force issued, I shall not employ any person inanymannerso asto become subject to the Work ers'CompensationLaws of
and effect, - � California.
License Class _ � - Lic. Number Date Applicant
Date�y�' —� Contractor _ _ : ���,,A?"• .r�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 must forthwith 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 W Beamed fer"k*
construct, alter, 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 a signed statement that he is licensed pursuant lothe provisions of the Contractor's License Law ❑ 1 hereby certify thatno excavation live (5) or more 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 work authorized by this permit, and that no building structure, scaffolding, lalsework, 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 (36) feet high. (Chap 3.2, Grp 2, Art 2,Sec341.Title8.
subjects the applicant to a civil penally of not more than live hundred dollars ($500.): C,A-C-)
❑ I, as owner of the properly, or my employees with wages as their sole compensation, will do the work, and the
structure is not intended or oflered for sale (Sec 7044, Business and Professions Code: The Contractor's License
Law does not apply to an owner of properly who builds, or improves thereon, and who does such work himself or
through his own employees, provided that such improvements are not intended or oflered for sale. II, however, the
building or_improvemni is sold within one year of completion, the owner -builder will have the burden of proving that
he did not build or improve for (he purpose of sale.).
❑ 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-)-
❑ 1 am exempt under Sec.
Owner
B_ & P.C. (Attached Certificate).
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 Wn Company
❑ Certified copy is hereby furnished, -
❑ Certified copy is filed with the City Building Inspection Department or City
Date Applicant
Department.
APPLICANT NAME (L. F, MI)
ADDRESS
CITY/COMMUNITY/STATE/ZIP
r �Desert. Q
JOB SITE ADDRESS/SPACE
r
CITY/COMMUNITY/STATE/ZIP
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PAG
PRC
C TWN
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TRACT
LOT
MOD SB
TRACT NAME
t:
OWNER NAME (L. F. MI)
ASSOC-
CONTRACTOR-FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 11
LICNC N
ARC/ENG FIRM NAME
T.A.D. Assawiates
ADDRESS
CITY/COMMUNITY/STATE/ZIP
Pala SCIr ' s
PHONE N"0-8899
LICNC N
USE OF PERMIT L:-\, T' 1_1 �j is Gate
BL I
I ZON
FSB
SSB I
SSE
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OFC
ZONE ORD M
LOT SZ
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SIDE
❑ As owner -builder, I 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;
❑ Division of Industrial Safety Permit No.
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 Addr—
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
Dale
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and slate 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 Salety to enter
upon the property for which I have applied for this permit for the purpose of making inspections,
Signatureof Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMT
` DAT
L-CN.4mir to inst 1. i
WD& n►+U and
electric entry gam as per
appxoved
plans.
Pl.ai7 Check Fee
Electrical Fee
7.0"
SM Fee
a5.
0oiist. Fee
332. J'.
r
i4^
is b
TOTAL
FEE
WLfr
BLDG. DEPT.
VALUATION
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
Of
Q
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
1Final
10A
fireplace T.O. ❑
OP'N ADDITIONAL INFORMATION
NO
/ J
SEWAGE SYSTEM SIZE & LOCATION
11
Exterior Lath
12
Internal Lathe/'�'�!v
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
PAL 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