BLCK (0850)52145 Avenida Martinez
0850
PERMIT APPLICATION
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.
• CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need 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. hcertify that in the performance of the work for which this permit is
(commencing with Section 7000) of Division Sof the Business and Professions Code, and my license is in full force issued; I shall not employany person in any mannerso as to become subject to the Workers'Compensation Laws of .
and effect. California.
License Class Lic. Number
Dale Contractor
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law.for the `;
following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct; alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
such -permit to file a signed statement that he is licensed pursuanito the provisions of the Contractor's License Law '
(Chapter 9(commencing with section 7000) of Division 3 o1 the Business and Professions Code)or that he is exempt
therefrom and the basis for the alleged exemption. Any violation of Section 7031.:5 by anyapplicant for a permit -
subjects the applicant to a civil penalty of not more than five hundred dollars (WO.): '., X^res •' ,
0 I. as owner,of the property, or my employees with wages as their sole,compensation, will do the work, and the
structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License, ,
Law does not apply to an owner of property who builds, or improves thereon, avid who does such work himself or
through his own employees, provided that such improvements are not intended or offered forsale. If, however, the
building or i mprovemnt is sold within one year of completion, the owner -builder will have the burden of proving that
he did not build or improve for the purpose of sale.).
0 I, asowner of the property; am exculsively contracting with licensed contractors to construct the project (Sec..
7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of property who ,
builds or'improves thereon,°and who contracts for such projects with a contractor(s) licensed pursuant to the
Contractor's License Law.).
011 am exempt under Sec.-. ■ r . B.'8 P.C. (Attached Certificate).
. ate yf tea— i 161-. 4.Owner
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 )
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
0 1 hereby certifylhat no excavation five (5) or more feet in depth into which a person is required to descend. will be
made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or
demolition or dismantling thereof.'will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2; Sec341, TitleB,
C.A.C.)
0 As -owner -builder; I will not employ anyone to do Work which would require a permit;from the Division of
Industrial. Safety,*as noted above, unless such person ha's a permit to do such work from that division.
0 Division.of,lndustrial Safety Permit No.
Date Applicant_
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the above information is correct. I agree to comply with all
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 inspection purposes.
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
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
0 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
upon.( eproperty.for wpich I have applied for'this permit for the purpose of !king inspec ions. ;7
Date Applicant ,f. / :.G fi/ C? .-/,—
Signature
-
Signature of Applicant or Agent" Date
APPLICANT NAME (L• F,
ADDRESS,.0 '
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CONTRACTOR -FIRM NAME ..
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Print Applicant/Agent Name
APPL/PRMT 08 0 DATE
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City of La Quinta
TOTAL
FEE
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VALUATION, (J j .
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
1 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.
❑
NPON ADDITIONAL INFORMATION
_
, 36 l
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
PSL 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