BLCK (0667)54650 Avenida Madero
0667
PERMIT APPLICATION
City of La Duinta'
Department of Building and Safety
This permit becomes void.if• work not commenced'within 180 days from date of
issuance. OR, ft 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. l certify that in the performance of the work forwhich this permit is
" (commencing with Section 7000) of Division 3of the Business and Professions Code, and my license'is in lull force
issued, I shall not employ any person in anymannersoasto become subject tothe Workers' Compensation laws of
and effect. L,1, p ? /
California. '
License,Class _ -Lic. Number•
^ f r p Y/J )xi
Date Applicant
Dale Contractor
NOTICE TO APPLICANT:. If, atter making this Cectificate.of Exemotion, you should become subject to the Workers'
OWNER -BUILDER DECLARATION: I hereby affirm that I am'exempf'from'the Contractor's License -Law for the
Compensation provisions of the Labor Code,,you must forthwith comply with such provisions or this permit shall
deemed revoked.
following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to
.*be
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 of the Contractor's License Law.
O I hereby certify that'no excavation five (5) or more feet in depth into which a person is required to descend, will be
• (Chapter 9 (commencing with section 7000) of Division 3 of the Business and.Protessions Code) or that he is,exempt
made in connection with work authorized by 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 341, Title 8,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
C:A'.C.) fl'.,W'Ic,• .
• O - 1. as owner;of the property. or my employees'with wages as their sole compensation, will do the work,.and the ;
O 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 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 Safety Permit No.
building orimprovemntissoldwjthinone year ofcompletion, the owner -builder will have the burden of proving that
Date Applicant "
he did not build or improve for.lhe 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 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 contractor(s) licensed pursuant to the
• Contractor's License Law.).
Lender's Address
. O 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 .
f Date Owner
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
SIDE
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 , ora certified copy tfiereof•(Sec 38001 -1 -ab. C.). ' •,
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Signature of Applicant or Agent Date
Policy.No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION'OFENTRY.. certify lhaveread this application and statelhat
O 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 copyfis filed witWe City Building Inspection Department or Clty — Department.
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construction, and authorize;a.'representative of the City of La,Quinta Department of Building and Safety to enter
have the
t } b .ter L' y .m r
upon -the property forwhich I applied for this permit for purpose of making inspections.
Date Applicant
Signature of Applicant or Agent Date
Print Applicant/Agent Name
`
ADDRESS 7/ 4A.e .
/
C,LTw ,YJEOJJMUNIT" 7 TE/ZIP
JOB SIITEPAADDRDDRRESS/SPACE -
` C-5
CITY/COMMUNITY/STATE/ZIP
L!-1, 4.12.
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PAC
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FIND
SE
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TRACT
LOT
.TOTAL •
FEE -
MOD
SB
TRACT NAME '
OWNER NAME (L, F. MI) ••
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP •- -
f
PHONE 1
,LICLNC 0
'
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP - -
PHONE N
LICNC •
-
USE OF PERMIT -
BL
ZON•FSB
SSB •'
SSB
RSB
OFC '-
' ZONE ORD 1
. LOT SZ ' "
END
SIDE
APPUPRMT 16
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7 rrl N C. '. / • '
.TOTAL •
FEE -
. 5
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
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.
❑
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ADDITIONAL INFORMATION
V 111,2 /
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