0757 (SOTB)PERMIT
APPLICATION
City of La Quinta
• Department of Building and Safety
This permit becomes void if work'not commenced within -180 days frorn 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 if -
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 manner so as to become subject.to the Workers' Compensation Laws of
-and effect.
California.
License Class Lit. Number-
S ��t
-Date Applicant
Contractor 121sitvI—A
OWNER-BUILDER DECLARATION: I hereby affirm that, I am exempt frLo`m` the Cibntraclor'sL—ic/ensie Law the
NOTICE TO APPLICANT:'If, after making'this Certificatiof Exemption, you should become subject lathe Workers'
Compensation pr.o.visions: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, -
be deemed. revoked.
*CERTIFICATION:
construct, alter, improve. demolish, or repair any structure, prior to its issuance, also requires the applicant for
DIVISION OFANDUSTRIAL SAFETY PERMIT
such,permit lo.file a signed statement.that he is licensed pursuantto the provisions of the Contractor's License Law
I hereby certify that no excavation five (5) or more feet in depth into which -a pirson 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, falsework�'&
therefrom and.the basis for the alleged exemption. Any violatiqn,ofiSection 7031.5 by any applicant for a permit
'demolition or dismantli6g*thereof, will be more than thirty-six (36) feet high: (Chap 1.2.' Grp2, Art 2. Se&341, Title 8.
subjects the applicant to a civil penalty of not more than five!huridred 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
b As owrfei:builder, I 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
Industriil:S I afetY, 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
LICNC 0
througKhis own employees. provided that such improvements are not intended or offered for sale: If, however, the
.0 Di.vision,of.1n.dustrial Satpty Permit No.
building or improverrint issoldwithin one year of completion. theowner -builder will have the burden of proving that
Date.- L - Applicant
he did not build or purpose jor improve for the rpose of sale.).
.. :. .. . .
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending abe'n'cy 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.).
7D44. 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
OFC
-Contractor's License Law.).
Lender's Address
0 1 am exempl'under Sec: B. & P.C. (Attached Certificate).
I certify that I have read this application and state that the above information;is correctJ agree to comply with all
Date 'Owner
city and county ordinances and state laws relating.to building construction, and hereby authorize representatives
END
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
cerlificate'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 I have read this application and state that
0 Certified copy is hereby furnished.
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
0 Certified copy is filW'witli the City Building Inspection Department or City Department
construction, and authorize a representative of the City of La Quinta Department of Building and Safely to enter' -
upon the property for which -I have applied for this permit for the purpose of making inspections.
Date Applicant
Signature of Applicant or Agent Date
0
AME 5i. MI
AN-T NAME-5i
/!l
)APtPL.I,C
ADDRESS
CITY/COMMUNITY/STATE/ZIP
JOB SITE ADDRESS/SPACE
jo
CITY/COMMUNITY/STATE/ZIP TY/1COMMUNITY/STATE/ZIP
1 0 41L-7,4
BOK
PAG
PRC
C
TNM
RNG
SE
S
TRACT
LOT
TOTAL-:
FEE
----------
MOD
SB
TRACT NAME
OWNER NAME (L F MI)
-7 &�721
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 0
LICNC 0
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 0
LICNC 0
USE OF PERMIT
OL
ZON
i
FS8
SSW.
SSB
RSB
OFC
ZONE _ORD
LOT SZ
END
SIDE'
Print Applicant/Agent Name
APPUPRMT n75"L♦A7
Irw
Aalz I -Jo
-7�
A
I P9.
TOTAL-:
FEE
----------
BLDG. DEPT.
YALUATION( 2
I
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
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 Cgiling (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 PAI
STREET NAME
26 Power Pole
27' Conduit
28 Service Entrance
.29.. Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final .
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CITY OF LA QUINTA
Community Development/Bldg. Dept.
CONDITIONALLY APPROVED
SUBJECT TO INSTALLATION! AS F71
AND ALL APPLICAG4."L:
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