PLBG (0583)52320 Avenida Madero
0583
PERMIT APPLICATION
City of La Ouinta Y '
Department of Building and Safety ,
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.
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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' 1
+ (commencing with Section'7000) of Division 3 of the Business and Professions.Code, and my licenseAs 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 al - Lic. Number, - .'
.: Date Applicant
' Date - -Contractor, - -
NOTICE .TO APPLICANT..:.If, after.making.this•Certificate of Exemption, you should become subject to the Workers' -
OWNER-BUILDER.DE&A'RATfO N: I hereby affirm that I am exempt from the Contractor's License L'aw4or the
n-provisions of the _Labor Code, you musl.torthwith comply with such_provisions or this permit shalt ••
Compebe
following reason. (Sec.' -7031.5. Business and Professions Code: Any city or county which' requires'a,permit to
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construct, alter, improve. demolish, or repair any structure: prior to its issuance: also requires the applicant for
4 DIVISION.OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:.. '
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law
O'therebycertify tliatnoexcavation five(5)ormore feet indepth into which aperson isrequired todescend.willbe
(Chapter 9(commencing with section -7000)of Division 3 of the Business and Professions Code) or that nets exempt
made in connection witti work' authorized by this permit, and thatno 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
-demolition or dismantling:iher'eof, will be more'ttim thirty-six (36) feet high. (Chap 3.2, Grp 2, AA 2; Sec341. Title B,'
subjects the applicant to a civil -penalty of not more than five hundred dollars.($500.):
C.A.C.)
Pt 1. as owner of the property: or my employees with wages as their sole compensation, will do -the work, and the - ;
Y
0 As owner•builder, t 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, orrimproves thereon, and who does such work himself or
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' through his own employees, provided that such improvements are not intended or offered for sale. If, however, the,
❑ Division of Industrial Safety Permit No.
building orjmpro3 emnt is sold within one year of completion, the owner -builder -will have the burden of piroving that. . _
Date Applicant
he did:n .1 build or improve for the purpose of sale.). , , _ ° , , '
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
-o i, as owner of the property,.am exculsively contracting with licensed contractors to construct ti'e project.(Sec:',v ' ,
of the work for which this permit is issued (Sec. 3097: Civ. C.)r
7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
' eilder's Name -
builds'or improves thereon, and who contracts for such projects with'a conlraclor(s)licensed pursuant -to the ' -
-
Contractor's License Law.).
Lender's Address '
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O I am exempt under'Sec. ' 6, 8 RC:.(Attached Certificate):-. -
I certify that I have read this application and state that above information is -correct. I agree to comply with all -
Date e /_ L i 4 `' Owner 1 = /' "0
r
: + city and county ordinances and state laws relating to building construction, and hereby authorize representatives . .
t-
of this countyto 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.).. t.
-
• Signature of Applicant or Agent Date
Policy.No. Company.
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: Tcertify l have lead this application and statethat "
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 '
O 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'
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upon the property for which I have appliedtor.t6 permit -for the purpose of making Iinspections.
Date Applicant
.. .. .. .. ,
Signature of Applicant or Agent • . Date
i ^— • Print Applicant/Agent Name
APPLICANT NAME (L, -F, MI ' • h ,
'ADDRESS •.. .. .
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CITY//COMyyMUNITYA SSTATE/ZIP '
JOB SITE ADDRESS/SPACE
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CITY/COMMUNITY/STATE/ZIP
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TRACT NAME -
OWNER -NAME (L. F. MI) • '°4:. ..
CONTRACTOR -FIRM NAME ' . •- • ' -
ADDRESS - .. ..
CITY/COMMUNITY/STATE/ZIP
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PHONE t
LICNC 0
ARC/ENG FIRM NAME -
ADDRESS
CITY/COMMUNITY/STATE/ZIP-
PHONE -N '
LICNC 8
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USE OF PERMIT - ..
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; •END:
SIDE '.
APPL/PRMT}['( DATE -
nS, 83
'TOTAL ':
FEE *
/S, "
BLDG. DEPT. r
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
1 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. qq 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
PI 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