BLCK (0648)_ PERMIT APPLICATION
h
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.,
• �`z.
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: ,This section need not be completed if
•.LICENSED CONTRACTORS DECLARATION: 1 hereby affirm that .Lam 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 Sof the Business and Professions Code, and my license is in full force
issued: l shall not employ any person in anymannerso asto become subject tothe Workers'Compensation Laws of tw :.•.
and effect.
California. —'
License Class Lic. Number '
Date Applicant
a
Date ContractorNOTICE.TO
APPLICANT: If, after making this Certificate of.Exemption, you should become subject•to the.Workers"-
Y•,
OWNER-BUILDERbECLARATION:' I hereby affirm (hat 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:permittofile asigned statement .that heislicensed pursuant to.theprovisions ofthe Contractor's License Law. r
-0 t' hereby' certify that no excavationfive (5)ormore feetindepth into which apersohisrequiredtodescend, will be, '
(Chapter 9 (commencing,wilh section 7000) of Division 3 of the Business and Professions Code) or that he is exempt;
made iri'connectiomwith workauthoriied by this permit. and that no building structure, scaffolding; falsework, or
therefrom pnd, the basis for the alleged exemption Any;violation of Section 7031.5 by any applicant for a permit
' to hundred dollars.(SSk):
demolition or dismantling thereof, will be more than thirty-six (36) feethigh. (Chap 3.2, Grp 2, Art 2:Sec 341, Title&
subjects the applicant a civil penalty of not more'than;five
ARC/ENG FIRM NAME .. '
.-,.0 L.as owner of the property. or my employees with,wages as their sole compensation, will do the work, and.the ,
19 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 empfoyeestprovided that suchAmprovements are not intended or offered for sale: If; however,the
❑Division of.lndusVial Safety Permit No. +
building or i mprovemnt is sold within one year of completion, the owner:builder wil l have the burden of proving that ...
.,—Date- Applicant
he -did not build or improve for the purpose of sale:); _
.,ca••...•' - -• `•
"CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lend . ing agency for the performance
0 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 witWa contractor(s) licensed pursuant to the.
Contractor's License Law.)." .. `/ ! 1"'
f `8
Lender's. Address
, : LOT SZ ^ •
'- 0 1 -am exempt u der -/g, ec. �P.C. (Attached Certificate)
•1 certify that I have read this application and state that the aboye.mformation is correct. -.1 agree to comply with all r
9`/
',. Date' _ ' '� �r Owner `'tl' '_ �'
city and county ordinances and state laws relating to.building construction, and hereby authorize representatives
/ t
of this county to enter upon the above=mentiorled property for inspection purposes. . �.
' WORKERS' COMPENSATION DECLARATION: I herebyraffirm that I havea certificate of consent to self -insure, ora
certificate of Workers' Compensation Insurance , or a certified cop f the i (Sec. -3800. Lab. C.):
"' w"
Signature of Applicant or Agent Date i
Policy No. Company
CERTIFICATE 6 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,
_ ..
upori the property for which I have applied for this permit for the purpose of making inspections. •.
.DatApplicant
e
....
Signature of Applicant or Agent Date
r
APPLICANT AME (L. F, 11 - ,
ADDRESS_ `17l • 1!'A�� � io v7 .�
CITY J�CO�M•+MUN- ITjY/STATE/21P - •'
JOB S•I W,OR ESSrPACE
CITY/COMMUNITY/STATE/ZIP
SOK.
PAG
PRC„
C
•
TWN•
RNG . - •
SE - •
S..
TRACT ..
LOT
[MOD
SEI
TRACT NAME -
OWNER NAME (L. F. M1) �. ... .. < .
CONTRACTOR -FIRM NAME
ADDRESS • -"
CITY/COMMUNITY/STATE/IIP a.
PHONE' f J 1V
LICMC F-
ARC/ENG FIRM NAME .. '
ADDRESS - .. ...
CITY/COMMUNITY/STATE/ZIP
PHONE • -
_
•LICNC, N
.,
USE OF PERMIT ,
BL
ZON
FSB
' • SSB
SSB`.,
RSB
OFC .;
ZONE' ORD N.--_..•
-
, : LOT SZ ^ •
-
END
• SIDE
Print Applicant/Agent Name
APPL/PRMT R !1 R It 4 '3j /O y BGA WA�
A_eel,,v i T -reo e, ,oA1 S -r eac T O
,a � •G /it/�•�G•-�T.' fit' - .3 �f°�1 �%� .
•:.. �� �N cam. /�•� i7
VALUATION
i 7,
REC'
•111.01ty Of LavuInfa
4t ,.
r ti. (•. -�.,; BLDG. DEPT.`
- TOTAL - :
, "/• . �"-
FEE- •'
VALUATION
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
zz
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. ❑
NON ADDITIONAL INFORMATION
LAllf 7
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)
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final