0487 (SOTB)PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
This'permit becomes void it work not commenced within 180 days from -date of issuance. OR, 'if work has been suspended or. abandoned'fora period of 180 days.
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CERTIFICATE OF EXEMPTION FROM WORKERSCOMPENSATION INSURANCE: This section need "not be completed itrsi
'LICENSED' CONTRACTORS DECLARATION: 1 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 -3 of the Business and Professions Code!and my license'isin full force
issued, l shall not employany person inn manner so asto become subject to the Workers'CompensationLaws oR-
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 IhaLl'am exempt from the Contractor's License Lawlor the
Compensation,provisions.of the Labor Code;you.must.forthwith comply with such provisions or this:permitshall ..
be'deemeilrevoked.
fallowing reason (Sec. 7031.5. Business and Professions Code:.Any city or county which requires a permit -to
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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 -to the provisions of the Contractor's License Law,
- ❑ 1 Kereby'certify ihit nd excavation five (5) or mori feet in depth iAto Which a person is required to descend. will be'
(Chapter.9 (commencing with section 7000) of Division 3 of the Business and ProfessionsCode)or that he is exempt .r.
rized.by this peimii, and that no building structu, scaffolding, falsework, or,. .
made in'connection:with v/ork authore
' therefrom and the basis for the alleged exemption. Any -violation of Section 7031.5 by'any applicant for a peimit ..
demolition or dismantling thereof, will be more than thirty -"six (36) feet (Chap 3.2, Grp 2, Art 2, Sec341, Title8,
subjects the applicant to a civil penalty of not more than five:hundred dollars ($500.):
C.A.C.)
• ❑ I. as owner of the'property:pr my emplgyees.wilh wages as their sole'compensation, will do the work„and the
❑ As -owner -builder, I will not employ anyone to do work which would require a permit from the Division-of-
ivisionol:structure
structureis not intended or offered for sale (Sec. 7044. Business and Professions Code:.The Contractor's License
Industria l' 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 -
Law
CITY/COMMUNITY/STATE/ZIP -
through his own employees, provided that such improvements are notintended or offered for sale. II: however, the .:
❑Division of Industrial Safety Permit No:
• building orimprovemniissoldwithinone year of.completion. the owner -builder will have the burden ofproving that
Date Applicant
he, did not build or improve for,the purpose of sale.): r ,
CONSTRUCTION. LENDING AGENCY: I hereby affirm that there is a construction lending agencyfor the performance
O 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 ownerof property who
Lender's Name
'builds or'improves thereon, and who contracts for such projects with a contractors) licensed pursuantto the
SSB -
Contractor's License Law.).
Lender's Address
❑ I am exempt under'Sec. B: 8 P.C. (Attached Certificate). ' ..
I certify that I have read4his application and state that the above information.is correct. I agree to comply with all ; . -
Date Owner ' ' ” '
city and county ordinances and slate laws relating to building construction, and hereby authorize;representatives
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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•insum or a
END-,
certificate of Workers' Compensation Insurance , or a certified copy thereof•(Sec'38001ab. C.)..
Signature of Applicant or Agent Date
Policy No. Company
,'CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRYs I'certify l have read this application and statethat: `
.❑ Certified copy is hereby furnished. .. •, - . . " - •
the information given is correct. I agree to comply with:allistate laws and'county:ordinances relating to buidling
E1ertifi6d copy is filed' wit the City -Building Inspection Depa .tment or City Department.
construction, and authorize a representative of the City of La Ouinta.Oepartment of Building and Safety to enter.
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upon the property for.which.l have applied for this permit for the purpose of -making inspections.
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Signature of Applicant or Agent Date
Print Applicant/Agent Name _a
APPLICA,�,T NAME (L', F. MI
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ADDRESS /� ` y/ �•�
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CITY/COMMUNITY. STATE/ZIP
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CONTRACTOR -FIRM NAME- •..
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE A
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LICNC #
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ARC/ENG FIRM NAME - -
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE •
LICNC
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USE OF PERMIT
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END-,
.:BIDE
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City
TOTAL
.. ' .. FEE
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
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.
Cl
NPON
ADDITIONAL INFORMATION
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
pIL 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