0326 (PAT)PERMIT APPLICATION 'S31,
• A 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,.ifwork 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 if '
LICENSED CONTRACTORS DECLARATION: Ihereby, affirm, that l am licensedunder provisions+of Chapter, 9
the�permit is'for one hundred ($100) o, less. ),certify that,in the performance of the work for which this'permit is
(commencing with Section 7000) of Division 3 of the Business and Prolessions.Code, and my license is in full force
issued, I shall not employ anyperson in anymannersoasto 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`, - i,.
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt'Irom tne'Contractor'sLicense Lawforthe
' • Compensation provisions of the Labor•Ca_de; you must forthwith comply with such provisions or this permit shall, •,r
following reason (Sec. 7031.5. Business and Professions. Code: -Any city or county which requires a permit to ' .'
be deemed revoked.
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 islicensed pursuant to the provisions of the Contractor's License Law,% ...
01 her ebycertifythat noexcavation five (5)'ormorefeet indepth into'whiihapersonisrequired todescend,willbe '
. (Chapter 9fcommencing with section 7000) of Division 3 o1 the Business and Professions Code) or•that he isexempt ' o
; made in connectiomwith work authorized by this permit, and that no'building structure, scaffolding,3Msework; or-
rtherefrom
therefromand the basis for.the alleged exemption..Any violation of Section•761.5 by any applicant;fora permit
demolition or dismantling thereof; will be.more than thirty-six (36) feet high. (Chap 3.2; Grp 2, Art 2;Sec30 Title 8,
subjects the applicant to a civil penalty of not more than five hundred; dollars ($500): " -
C.A.C.)
0 1, as owner of the property, or my.employees with wages as their sole compensation, will do the work, -and the
0 -As owner-buifdei,'l will not employ anyone to dd work which would require.a permit from the Division of :•.
structure isnot 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 permitto..do.such work from that division.
Law does.not apply to an owner of property who.builds, or improves thereon, addwho does such work himself or
O Diyisfoa of IndustriaLSafety Permit. No.
through his own employees, provided that improvements are not intended or offered. for sale. If, however, the,,
building,or.improvemnlis sold within one year of completion, the owner -builder will have the burden of proving that..
Date Applicant .�
he.did:notbuild or,improve for the purpose of safe.).
.. . � r; . .. .
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agencylorthe performance
0 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 owner of.property who
n
Leder's Name
.'builds or improves thereon; and'who contracts'for such projects with a contractor(s) licensed pursuant to the.
- •r'. - -
Coniractor's License Law.).
Lender's Address a
0 l am.exempt under. Sec., B. 8•P.C. (Attached:Certificate).
I certify that.) have read this application and state that the above,information is,correcti agree to comply with all .,
//�/'
! . Y' Owner`"i �' /J '�"j �-
city and county ordinances and state lawsaelating to building construction, and hereby authorize representatives e
of this county'to enter upon the above=mentioned property for inspection purposes..
• WORKERS' COMPENSATION DECLARATION: I he�eby,affirm that I have a,certilicafe of consent to sell -insure: or a
certificate•of Workers' Compensation Insurance'.,:or a 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 l have readthis application andstate that'
' 13 Certified copy is hereby furnished.the•information
given is correct..) agree to comply with all state laws and'county ordinances relating to buidling
' 0 Certified copy is filed with the City Building Inspection Department.or City Department.
construction, and authorize. a'representative of.the City of. La Ouinta Department of. Building and Safety to enter ,.
the property for. which.I have, applied for this.peimit for the,purpose ol�making in :.. .. -
Date Applicant.
� � .
.. .. .. .. ..
Signature of Applicant or Agent Date
t �
_♦
Print Applicant/Agent Name
APPLICANT NAME (L, F, MI) —3-
011AI Sot l/ /� Q
ADDRESS
STATE/ZIP dA. -
PSPPAAACE
JOB SITE ADDRESS/SPACE
CITY/COMMUNITY/STATE/ZIP
BOK
PAG
PRC
C
TNN
RNG
. SE.-
S
TRACT
LOT
MOD
SIB
TRACT NAME '
OWNER NAME (L. F. MI) '^
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/IIP -
PHONE •
LICNC II
ARC/ENG FIRM NAME -
ADDRESS.
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC.N
,
USE OF PERMIT
-8L
ZON'FSB
SSB
SSB
RSB
OFC..
.ZONE ORD •.'LOT
SZ.
' END.'
SIDE. '
APPL/PRMT• DATE �®/ •n/��
A,cel,v Ir ,Q4 710
�G��i9D G'ONST�PULF��
MIL n
V. E
P,6�UR4_ 7y
ity.0 La
,:TOTAL
.. FEE
5•��r3-:.
y ,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.
❑
NPON ADDITIONAL INFORMATION
A l/
7
'
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lathe_
12A Drywall
13 Finish Grade
INSULATION Thick R"
Value
7A Walls (Batts)'
12B Ceiling (Batts)
12C Ceiling (Blown)
14 1 Finale
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 P/I
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring .
29A Grounding Wire
298 Bonding
30 Fixtures
31 Service
32 Final