0675 (BLCK)•PERMIT.APPLICATION
City of La Ouinta
Department of Building
and Safety
This permit becomes void if work not commenced within.1804ays from date•'of issuance..OR.
if work has been: suspended -or abandoned for a period of 180 days.
PAG
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 the Business and Professions Code, and my license'is in full force
issued: I shall not:employ any person in any mannecso as to become subject to the Workers'Compensation Laws of .
and effect.
California.
.License Class Lic. Number
Date :Applicant
' Date Contractor
NOTICE TO APPLICANT:r lf;,aftermaking thisCertificate of Exemption, you should become subject to the Workers'. '
OWNER -BUILDER DECLARATION: • I.hereby a1f4m that I am exempt from the Contractor's License Lawaor the
Compensation..provisions of-tthe:LaborCode,-you must 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 permil.to .'
TRACT NAME '
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 lidensed pursuant tb4he provisions of the Contractor's License Law
-- 6 the certify that noexcavation five(S�ormorefeetindepth'intowhichaperson isrequired todescend, 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, falsework,or
therefrom:and the basis,lor the alleged exemption: Any violation of Section 7031.5 by any applicant. for a permil
demolitjon ordismantliny thereof; will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2 Art 2, Sec341, Title6. '
subjects the applicant to a civil penally of not more than five hundred dollars ($500.): .•
C.A C )' ..t, k 1*• .
❑ I..as.owner o1 the:property, or my employees with vrages as their sole compensation, will.do the work, and the
.. p As owner -builder, I will not employ anyone to do work which would require a permit from the Division -of '
structure js not intended or- offered for sale (Sec. 7044. Business and Professions Code: The Contractor's License'. " ..
"Industrial 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
USE OF PERMIT "
' . through his'ownemployees. provided that such improvements are not intended or offered lor.sale. If, however,.lhe
O.Division of Industrial Safety Permit No.
building or improvemnt.is sold within oneyearof completion. the owner -builder will have the burden of proving 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 agency for the performance .
• 0 I, as owner ot.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 ' ..
ZONE'ORD N'•
Contractor's License Law.).
Lender's Address -
ddress01
0 1am exempt under Sec: '.'B, 8 P.C. (Attached Certificate).. . •
I certifythat.l have read this application and slate that the above information.is correct: I agree to comply with all
" Date' Owner '
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.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a
-
'certificate otWorkers' Compensation'Insurance , or a. certified -copy thereof (Sec. 9800. Lab.•C.): '
Signature'of Applicant or Agent Date
Policy No. Company. ,
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:1 certify I have read this application and state that.
_ O Certified copy is hereby furnished.
the information given is correct. I agree'to:comply with all state laws and county ordinances relating to buidling
.A Certified,copy is filed with the City Building Inspection Department or;City11� Department:
construction, and, authorize a'representativenof the City of La Ouinta Department of Building and Safety to enter
for have for inspections..
F )
f,•� _ L_-T1��lMto
Date Applicant LV /,A!
upon the property -which I applied.for this permit the purpose of making
�
Signature of Applicant or Agent Date
Print Applicant/Agent Name
NAME (L��®ri/ .77��Cr i ION
APf-PLICANT ,4`,C.
A/DD/L%D✓<`�1
RESSM
CITY//COMMUNITY/STATE/ZIP
CL
JOB SITE ADDRESS/SPACE lF. Oldle C 6-Q
CITY/COMMNtTY/STATE/ZIP ,
G.4 z "74
Box
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TRACT
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TRACT NAME '
OWNER NAME (L. F. MIJ -
CONTRACTOR -FIRM NAME - -
ADDRESS '
CITY/COMMUNITY/STATE/ZIP .•
;PHONE
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ARC/ENG FIRM NAME '
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE .$
LICNC 8
USE OF PERMIT "
BL
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FSB
SSB
SSB
RSB
OFC
ZONE'ORD N'•
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END
'SIDE'•..,
APPUPRMT DATE •-/�}^'�/ `�7
,r TO (r a.c/s7,e6,,Ci
-< 6r rr O
OrC'JIAJr'�h./CG5- S G iAJ ,r
7.914 c7 v
RECEIVED
ASN L 4 *'084:
T i TOTAL' is "
FEE
/'
7(�
VALUATION'
.r BLDG. DEPT.
NO.
OPERATION DATE INSPECTOR
NO. OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back33
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
�ro7o2
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.
❑
OP'NO. ADDITIONAL INFORMATION
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 3
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
pI PyI
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final