BLDG (0678)PERMIT APPLICATION
City of La Duinta � �C
• Department of Building arid Safety
This permit becomes void it work not commenced within 180 days from date of issuance, OR, if work fias 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: 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. `, is ;
License Class Lic. Number
Date— Contractor .
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for4he
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 pursuant to the provisions of the Contractor's License Law
(Chapter9(commencing )Nithsection 7000)ofDivision3ofthe,Business. and Professions Code).or that heis exempt .
,therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any ;applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500:):1 , •,.
O I, as owner of the property, or my employees with wages .astheir sole compensation, will do the work, and the
structure is notintended.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, and who does such work himself or
through his own employees, provided that such -improvements are not intended or offered for sale. ll, however, the
building orimprovemntissoldwithinoneyearofcompletion, the owner -builder will havethe burden of provingthat
he did not build or improve for the purpose of sale.).
❑ 1, as owner 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 anowner 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.).
0 I -am exempt -under Sec. •. B. & P.C.. (Attached Certificate).
Date" Owner
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 thereoV(Sec. 3800. Lab. C.).
Policy No. Company - -
/C\Certified copy is. hereby, furnished. ]:
O Ce 'tied copy is ded with the City Building InsPedttion'Departme tjoxty Department
Date ` G� 7 Applicantj�'�r✓�
APPLIC �N,T NAME (L F, M1)w��Ql r�
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ADDRESS'
` ,1- 723 �v� /t✓�r3N flu
CITY/COMMUNITY/STATE/ZIP -
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JOB SALE ADDRESS/SPACE
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PHONE .-
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ARC/ENG FIRM NAME -
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USE OF PERMIT s"
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END
SIDE:
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:.
O l hereby certify'that 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, Title B; +
C.A.C.)
10 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 has a permit to do such work from that division.
y O Division of Industrial 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. l 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.
Signatul a of Applicant or Agent Date
:CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certif 1 have read thisapplication and state that
Y
N the information given is correct. l agree to comply with all state laws and county ordinances relating to buidling
construction, and authorize a representative of 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.
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPVPRMT DATE
C -A Cc161
INED
La QuilRa ,
TOTAL
7,i e /
BLDG. DEPT.
VALUATION 1 .y,12 _S 7,/
W
NO.
-OPERATION DATE INSPECTOR
NO.
OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Ser 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
z19
38
J 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
1 Final
10A
Fireplace T.O.
❑
NPON
ADDITIONAL INFORMATION
Fop- r2cM®DcZ
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"
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
„R,.
INSULATION Thick Value
7A Walls (Batts)/C
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
i PLUMBING APPROVALS
15 Ground Plumb
16 Water Piping
17 Rough Plumb 771'-
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 PiI
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance '00,07"4W as
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtuies
31 Service
32 Final