BLCK (0682)52350 Avenida Madero
0682
PERMIT APPLICATION S .3 ✓ VY)
City of
La Ouinta
^ - Department of Building and Safety
CITY/COMMUNITY/STATE/ZIP • -
BOK
^ This permit•becomes void it work not commenced -within 180 days from date of
issuance;'OR, if work has been suspended or,abandoned for.a'period.of 180 days.
4, `
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if -
•LICENSED CONTRACTORS DECLARATION:. I hereby. affirm that.1. am licensed under, provisions of. Chapter 9 ,;
the permit -is for one hundred ($100) o, less. [,certify that in the,performance of the work for which this permit is ..
(commencing. With Section 7000) of Division 3 of the Business and Professions Code, and my license is in lull force
issued, I shall not employ any person inany manner so as to become subject to the Workers:Compensation Laws.of ;
and effect.
California. ,
..License Class Lic. Number •-
,. Date _ Applicant -
Date Contractor. .'•' - = ^•
,. NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers:
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from t'he•Contractors License'Law for the
. Compensation provisions of lhe.labor-Code. you musLforlhwith complywith such provisions or -this permit shall
following reason (Sec. 7031.5. Business and Professions Code,.Any city or county which requires.a.permit to
be del med revoked:
construct, alter; improve, demolish. or repair any structure; prior to its issuance, also requires the applicant for
DIVISION OF -INDUSTRIAL SAFETY. PERMIT CERTIFICATION: ,
such permil.to file ' a signed statement that he is licensed pursuant to the provis.ions of the Contractor's License Law ^OlherebycertifythatnoexcaJation.live(5)ormorefeefindepthintowhichapersonisrequiredtodescend,willbe-
•.- (Chapter 9(commencing with section 7000) of. Division 3 of the Business and Professions Code) orthat he is exempt:made
in connection -with work authorized by this permit, and that no building structure: scaffolding, lalsework; or .
therefrom and the basisifor the alleged exemption. Any violation of Section.7031;5 by -any applicant for, a permit ..
.. demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2. Grp 2. Art 2; SBc341: Title8,-.
subjects the applicant to a civil penalty of not more than five hundred dollars,($&&.): -
C.A.C.)',
<' I: as owner of the property, or my employees with.wages as their sole compensation, will do the work, and the
0 As owner -builder, I will.not'employ anyone to do work .which' would require a permit from the Division of
structure is not intended or offer for saIe.(Sec. 7044. Business and Professions Code: The Contractor's License
Industrial Safety, as noted above, unless such person' has 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
-
'
through his own employees, provided that such -improvements are not intended or offered for sale. lf;however; the .
, 0 Division of Industrial Safety Permit No..; J
building or improvenint is sold within one year of completion. the owner -builder will have the burden of 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 agencyfocthe performance
..,0 Las 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, Ow 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 for such projects with a contractor(s) licensed pursuant to the
Contractor's License Law.). •
Lender's Address
• .0 .111 aamlexempt under Sec 1 B. &P C(Attached Certificate)."
- \
I certify that I'have read.this application and state that the above -information is correct.,) agree to comply with all
city and county ordinances and.state laws relating to building construction, and hereby authorize, representatives
Own e . ` `
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, ora :
certificate of. Workers' Compensation Insurance : or a'certiIied copy thereol (Sec°3800. Lab. C.). • . "
Signature ol'Applicant or Agent " Date .
Policy No Company,
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF. ENTRY': I'certify 'I have read this application'andstate that .
_• -0-Certified copy. is hereby furnished. ;••?r; ..
the information given is correct. I agree to comply with all,state laws and county ordinances relating to buidling.. 2 .
O Certified copy is diled with the City Building. Inspection Department or City ' Department..: s
construction, and.authorize a: representative of the City of La Ouinta Department of Building and Safety to enter, -
'upon the property for which 1 have applied for this permit for the purpose of making inspections.
Date .Applicant
Signature of Applicant or Agent Date
APPLICANT, AM ( F. MI)
4 C IF \J LTjv !
,ADDRESS ))
G^• . V i^ CLD.,, B i% Q,Y u . ,.
CITY/COMMUNITY/STATE/ZIP
JOB SITE ADORESS/SPACE .. -
CITY/COMMUNITY/STATE/ZIP • -
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PRC
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TRACT
LOT
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TRACT NAME • ' - . .
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OWNER Nr--,. L,.F, MI) /t. •-- 5, )-t'C
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CONTRACTOR --FIRM NAME
AODRESS KA (2
CITY/COMMUNITY/STATE/LIP •.
PHONE 11
LICNC 0
. 1 ..
ARC/ENG FIRM NAME -
ADDRESS .,
CITY/COMMUNITY/STATE/ZIP -
PHONE N
LICNC M
,
USE OF PERMIT
81.
ZON
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SSBI
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. RSB
OFC'..-
FC.:;ZONE
ZONEORD. •rte'.,
LOT.SZ:•
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END
SIDE '
• Print Applicant/Agent Name
APPL/PRMT- `. .
le
TOTAL
• FEE -
,VALUATION CiYJ t/C 7
i
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
/
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! /
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/1
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final