0676 (GRD)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 workhasbeen suspended or -abandoned lora 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 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 o1 the Business and Professions Code, and.my license is in full force -
issued„1 shall not employ any person in any manner so as to become subject tothe Workers'Compensation Laws.of. -
and effect.
California.
License Class. Lic. Number
Date Applicant
y
• -Date -` Contractor.
the Workers'.
NOTICE TO APPLICANT: If, after making this Certificate of ExemptipA,:you should.become subject to ;
” VWNER-BUILDER DECLARATION: �I hereby affirm thaPl am exempt from the Contractor's License Law for
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Compensation provisions of the Labor Code, you must forthwith comply,witb,such provisions or this,permitshall
' be deemed revoked:
following reason (Sec. 7031.5. Business and Prolessions.Code: Any city :or county which requires a.permit to
TRACT NAME '
construct, alter, improve. demolish, or repair any structure; prior to its issuance: also requires the applicant for.
. - DIV ISI ON,OF INDUSTRIAL,SAFETY PERMIT CERTIFICATION:
• such permit to.lileasignedstat mentthateislicensedpursuanttotheprovisions'oftheContractor'sLicenseLaw' ,
certifyihatnoexcavationfive(5)ormorefeetindepthintowhichaOersonisrequiredtodescend,Willbey
(Chapter.9 (commencing with section 7000) of Division 3 of the Businessand ProfessionsCode) or that he isexempi
made in connection with'work'authorized by this permit; and that no 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 .-.. ..,
demolitionbr disihantling thereof; willbe more than thirty-six (36) feet higfi:'(Ch4p3.2, Grp 2. Art 2, Sec 341, Title 8,
subjects the applicant to a civil.penalty of not more than five hundred dollars.($500.):.
ADDRESS
0 L. as owner of the property, or my employees with.wages.as their sole compensation, will do the work, and the
0 As.owner•builder, P will not employ'anyone to do 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 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 own employees, provided that such improvements are not intended"or offered for sale. Il,however, the.
0 Division of IndustrialSafety. Permit No.
building orimprovempt is sold within one year of completion. tkq owner -builder will have the burdenof proving that,
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 performance.
0 1, 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 forsuch projects with a'contractor(s) licensed!pursuanTto 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•informatioois 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: d hereby affirm that I have a certificateof consent to self -insure, ora'
certificate of Workers' Compensation Insurance , or 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
❑ Certified copy -is hereby furnished.
the information given is correct.] agree to comply with all state laws and county ordinances relating to buidling
X17 Certiliedf gpy`'s fit d.with the City Building Inspection Departmentroi City r f Department : '
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construction, and.authorize a.representative'of.the City of La 0inta Department of Building and Safety to enter,
u on she' propert for which I have applied for this permit for, the ur ose of makin ins ections•.
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Signature of Applicant or Agent Date
APPLICANT NAME (L. F, MI)
ADDRESS .._• l .. ..
CITY/COMMUNITY/STATE/ZIP
JO1BSE ALLODR�`�II� ACE�A / ,,!5- U /V
CIITTY/COMMUUNITY/STATE/ZIP
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TRACT NAME '
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME
ADDRESS
'CITY/COMMUNITY/STATE/ZIP
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ARC/ENG FIRM NAME .
ADDRESS
CITY/COMMUNITY/STATE/ZIP
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USE OF PERMIT
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Print Applicant/Agent Name
APPL/PRMT -ST - //O 1// r/l lel
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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.
❑
NP'N 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
PSL Pel
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final