BLCK (0368)53875 Avenida Madero
0368
41% _
Ar,.
PERMIT APPLICATION 3 O 6, rrL
City of La Ouinta
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. '
ADDRESS' 4
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 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 Lam exempt from.fhe Contractor's license Law for the
Compensation provisions 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 requiresa permit to
be'deemed 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 permit to file a signed statement that he.is licensed pursuant to the provisions ofthe Contractor's License Law
—01Nerebycertifythat noexcavation five (5)or-more feet indepth,intowhich aperson isrequired todescend, will be
(Chapter 9 (commencing with section 7000) of Division -3 of the Business and Protessions Code)or that heis,exempt
made in connection with work authorized by !his permit, and that no building structure. scaffolding, lalsework, or
therefrom and the basis for •the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
dernolilion'or disinkiling thereof, will be more than thirty-six (36) feet high. (Chap 3.2: Grp 2, Art 2; Sec 341, Title 8,
subjects the applicant to a civil penalty of not more than live hundred dollara,($500.):
•CAC) ..
-O. I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and.the
0 A owner•buifder; I will not employ anyone to do work,kvhich would require.a permit from the'Division of
structure isnot 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, 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. If, -however. the
O. Division of Industrial.,Safoty Permit No
• building orimprovemntissoldwithinone year ofcompletion: the owner -builder will have the burden of proving that.
Date Applicant
he did not build or impr,,'0 -, ,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 the project (Sec:
of the work for which thisi permit is. issued (Sec. 3097, Cir. 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 1 am exempt under Sec. B. 8 P.C. (Attached Certificate):-
1 certify that I 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.inspettion purposes.
WORKERS' COMPENSATION DECLARATION I hereby affirm than have a certificate of consent to self -insure, or a
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 I have read this application and state that
• ❑Certified copy is hereby furnished.
the information given is correct. l agree to comply with all state laws and county ordinances relating to buidling
O Certified copy is filed with the City Building Inspectiow6epartment or City Department.
C /
construction, and authorize a'representative of the City of La Ouinta Department of•Building and Safety to enter., .
upon the for which I have applied for this for the of inspections.
• /'? +// / T i
- ,if n _
Date AOplicant, -
property permit purpose making •
Signature of Applicant or Agent Date
A KJ NAME (L. F,41)1
ADDRESS' 4
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TOTAL
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TRACT NAME -
OWNER NAME (L, F. Ml)
CONTRACTOR -FIRM NAME r
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE N '
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LICNC /
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ARC/ENG FIRM NAME -
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE o
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USE OF PERMIT
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SSB
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Print Applicant/Agent Name
APPU/PRMT DATE
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01 La Winto
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TOTAL
FEE
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BLDG. DEPT. VALUATION
NO.
OPERATIONDATE
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.
❑
OP'NO. ADDITIONAL INFORMATION
r/%/ ` /v a` 7/i/ 7,
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 .Internal Lath
12A • Drywall
13 Finish Grade
INSULATION Thick al
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
PSL 0A
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final