BLCK (0741)„� 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, it work has been suspended or abandoned for a period of 180 days.
PAG
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 asto 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: 1 hereby affirm that I am exempt 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
following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a 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 oltheContractor's License Law -
0 1 Kerebicprtify that , no ixcavation 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 Professions Code) or that he isexempt
made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or
therefrom -and the basisfor 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, Sec341, Titlell
subjects the applicant to a civil penalty of not more than five hundred dollars (5500.): 1„ ,. x - I
CAC.)
❑ 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 offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Industrial Safety, as notedabove, 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
1^ .
through his own employees. provided that such improvements are not intended or offered for sale. If, however, the
0 Division of Industrial Safety Permit No.
building or improvemnt is sold Within one year of completion, the owner -builder will have the burden ofprdvingthat
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 agency for the performance
❑ I, as owner of the property, am exculsively contractingwith 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
❑ 1 am exempt under Sec. B. & P.C. (Attached Certificate).
I 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
W R R' P AT0 RAT h b it' h h f 1
of this county to enter upon the above-mentioned property for inspection purposes.
KE S COM ENS ION DECLA ION. I ere y a Irm t at I ave a cert) Icare o consent to self -Insure, or a
certificate of Workers"Compensation Insurance , or a certified copy thereof (Sec: 3800: Lab. C.).
Policy No. Company
O Certified copy is hereby furnished.
❑ Certified copy is filed with the City Building Inspection Department or City Department.
Date Applicant
APPLICANT NAME ``(L, F. MI)
c-,
ADDRESS `-..�.�
CITY/COMMUNITY/STATE/ZIP
JOB SITE ADDRESS/SPACE- �') p A }„y
CITY/COMMUNITY/STATE/ZIP
BOK
PAG
PRC
C
TWN
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S'
TRACT
LOT
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SB
TRACT NAME
OWNER NAME (L, F. MI) ;
CONTRACTOR -FIRM NAME
'ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE M
LICNC 11
t"
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE •
LICNC •
USE OF PERMIT
BL
ZON
FSB
SSB
SSB
RSB
OFC
ZONE ORD N
LOT SZ
END
SIDE
2
R1
0
Signature of Applicant or Agent Date ”
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF'ENTRY: I certify I have read this application and state that
the information given is correct. I agree to comply with allstate laws and county ordinances relating to buidling -
construction and"authorize a'representative O the City of La Ouinta Department of Building and Safety to enter
upon the property for which I have applied for this permit for the purpose of making inspections: e—
Signature of Applicant or Agent i % Date
Print Applicant/Agent Name
APPL/PRMT
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BLDG. DEPT.
VALUATION
u '
N.10
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.
❑
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)
12CT 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 PiI
STREET NAME
26 Power Pole
27 Conduit
28• Service Entrance
29 Wiring
29A Grounding Wire
296 Bonding
30 Fixtures
31 Service
32 Final