BLCK (0768)51984 Avenida Madero
0768
44 PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
-: l - 2S -q
This permit becomes void if work not commenced within 180 days from date of issuance, OR, if work has been suspended or abandoned for a period of 180 days.
LICENSED CONTRACTORS DECLARATION: I hereby affirm. that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force
and effect.
License Class Lic. Number
Date Contractor
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for the
following reason (Sec. 7031.5. Business and. Professions Code: Any city or county which requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
such permit to file a signed statementthat he is licensed pursuant to the provisions of the Contractor's license law
(Chapter 9 (commencing with section 70()0) of Division 3 of the Business and Professions Code) or that he is exempt
therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant fora permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
0 I. as owner o1 the property, or my employees with wages as their sole compensation, will do thawork, and the
structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Law does not apply to an owner of property who builds, or improves thereon, avid who does such work himself or,•
through his own employees, provided that such improvements are not intended or offered for sale. If, however, the
building or i mprovemnt is sold within one year of completion, the owner -builder will have the burden of proving that
he did not build or improve for the purpose of sale.). -
0 I, as owner of the property, am exculsively, contracting wilh,licensed contractors to construct the project (Sec.
7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the
Contractor's License Law.).
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section neednot be completed if
the permit is for one hundred ($100) o. less. I certify that in the performance of the work for which this permit is, .
+ issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of
California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption.,you,should become subject to the Workers'
Compensation provisions of the Labor Code, you must forthwith comply:with such provisions or this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:, .
0 I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be
made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or
demolitiomor dismantling thereof; will be more than thirty-six (36) -feel high. (Chap 3.2, Grp 2, Art 2, Sec 341, Title 8,
C.A.C.) I
0 As owner -builder, I will not employ anyone to do work which would require a permit from the Division of
Industrial Safety, as noted above, unless such person has a permit to do such work from that division.
0 Division of Industrial Safety Permit No
Applicant
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
of the work for which this permit is issued (Sec. 3097, Civ. C.):
Lender's Name
Lender's Address
0 1 am exempt under Sec. ' B. 8 P.C. (Attached Certificate). I certify thafl have read this application and state 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 of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. C.). w
Signature of Applicant or Agent 'Date
Policy No. Company
r - CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
❑Certified capy: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 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
upon the property for which I have,applied for this permit for the purpose of Zing inspec'ons.
Date Applicant rl!
Signature of Applicant or Agent Date
APPLICANT NAME (L, F. M111-0
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ADDRESS
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CITY/COMMUNITY/STATE/ZIP
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OWNER NAME (L. F. MI) +. -
CONTRACTOR -FIRM NAME
ADDRESS
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PHONE ILICNC.
ARC/ENG FIRM NAME ,
ADDRESS
CITY/COM MUN ITY/STAT E/ZI P
PHONE •
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USE OF PERMIT
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TOTAL
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Print Applicant/Agent Name
APPUPRMT
DATE `/,. /
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BLDG. DEPT. VALUATION j vLJ
NO.
OPERATION DATE
INSPECTOR
NO. OPERATION I 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.
❑
OP'NO. 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
p/L 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