CPWU (0346)52360 Avenida Madero
0346
PERMIT APPLICATION , 4
City of La
Ouinta
.. - Department of Building
and Safety ti
- ^ 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.
PAG
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE:..This-sectionneed not be completed if -
LICENSED: CONTRACTORS' DECLARATION:. 1. 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 otthe 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 anyperson inany mannerso asto become subject to the Workers'CompensationLaws of '
and effect.
California.
License Class Lic.•Number
_Date . Applicant.
= Mate • •-, • --• -"Contractor - - .., _
-.. NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to,the_W.orkers:._, , "•.'
is ^
`'OWNER -BUILDER DECLARATION:-']' hereby affirm'that,tam exempt from the.Contractor's License Law for -the
Compensation provisions of the Labor Code, you must forthwith comply withsuch provisions or this.permit shall- , . •c
.'
following reason (Sec.'7031.5, Business and Professions Code: Any city or county which requires a permit to .
be.deeined evakeA:
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 is licensed pursuant tothe.provisionsoflheContractor's.LicenseLaw
d I hireby certify that no excavati on five (5) or more f6el in depth inl6which a person is required to descend. w ill be
- (Chapter 9(commencing wifh,section 7000) of Division 3 ofdhe Business and Professions Code) or that he is exempt. .: t .. ,
',
made in connection with work authorizedby this permit; and that no 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 thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec 39.1, Title 8,
subjects the applicant io.a.civil penalty of not more than five hundred dollars ($500.): K
C.A.C.(
o Las owner of the property, or my employees with wages as their sole compensation, will do the work, and the .
❑ As owner -builder, I -will not*imploy anyone to do work -which would require a permit from Ihe'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 haia permit:to do.such. work from that division,...
Law does not apply to an owner otproperty who builds, or improves thereon, and who does such.work himself.or• .
.
' through.his own employees, provided that such improvements are not intended or offeredfor sale' If, however, the ' „ '-
• O Division of, Industrial SafetyPermit No.
building orimprovemntissoldwithinoneyearofcompletion,theowner.builderwillhavetheburdenofprovingthat-
Date Applicant .
he did.not build or improve for the purpose otsalea.
.. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a consOuction lending agency for the performance
-❑ I as owner of. the property, am exculsively contracting with licensed contractors to construct the project (Sec: .:_..;:..
of lhewwork forwhich 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
Lender's Name '
builds,or'improves thereon,'and who contracts for such projects with a.contraclor(s) licensed pursuant to the
'ZONE ORD .
.Contractor's License Law.). ; r. , {
-,Lender's Address
n
I. am exempt/under Sec ... B)& P.C. (Attached Certificate);..
I certify.that,l-have read this application and state that the above:information is correct. I agree to comply with.all '
JDate 2l ' '; Owner / 7 ;J.
,,w
city and county'ordinances ondslate laws relating to building construction, and hereby authorize representatives
r. ,_ •- 1 ; % - I . '
of this county to`enter upon the above=inentioned property for inspection purposes:
WORKERS` COMPENSATION DECLARATION: I hereby -affirm that l have a certificate otconsentto self -insure; ora .
-' 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 read this application and state that
'. ' o:Certified, copy is hereby furnished. " ,. r
the information given is correct:•]' agree to comply with all state laws and county.ordinances relating to buidling .
' D Certified copy is filed with'the City,Building Inspection'Deparin entor City Department.. ' . :.
. ',construction, and authorize a representative of the City of La Ouinta Department of Building and Safety to enter
• --
upon .the property for whichThave applied for this permit for the purpose of making inspections. .
Date Applicant
Signature of Applicant or Agent Date
_
Print Applicant/Agent Name
-APPLICANT NAME (L, F, Iil) > "
%F! I KC b
ADDRESS` -( +
CITY/CO/ MMUUNNIITTY/STATE/ZIP , ..
JOB SITE ADDRESS/SPACE 1•'
CITY/COMMUNITY/STATE/ZIP
F+ QJr
BOK' -
PAG
PRC
C
TWN
RNG
SE '
'S
TRACT
- LOT'
-
MOD
SB,
-
TRACT NAME .• - ,
OWNER N(A;ME (L, F. Ml) f -
CONTRACTOR -FIRM NAME
ADDRESS .
CITY/COMMUNITY/STATE/ZIP
PHONE . •''
LICNC4.1. /
ssgg
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC .
USE OF PERMIT
BL
,ZON
FSB
SSB.
SSB"
RSB
„OFC,.
'ZONE ORD .
LOT SZ ' ",
END r
, SID
APPUPRMT DATE
.146
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1VIIr JIN1
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City ®f La QQU
uin a
wfill
• 1 ,
TOTAL
FEEL. c: U
VALUATION
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
X38
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)
T=I=
126 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
STREET NAME
P/I
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final