RPL (0727)• LICENSED CONTRACTORS DECLARATI
(commencing with Section 7000) of Div'
and effect.
License Class Lic. Number
Date - • Contractor
L'
OWNER -BUILDER DECLARATION: I hereby atfirrti that Lam 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 asigned statement that he is licensed pursuant to the provisions of the Contractor's License Law .
(Chapter 9 (commencing with section 7010) of Division 3 of 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 any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): '
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, 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
building or improvemnt,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, 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 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.).
0 1 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 , or a certified copy thereof (Sec. 3000. Lab. C.).
Policy No. Company ,
0 Certified copy is hereby furnished. . ••
0 Certified copy is filed with the City Building Inspection Department or City ' Department.'
Date Applicant -o
PERMIT APPLICATION
City of La Duinla
Department of Building and Safety
,This, permit becomes void if work not commenced within 180 days from dateof 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
ON: 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
Divi 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'CompensationLaws of '
California.
APPLICANT NAME (L, F, MI)
ADDRESS 3(0 )o CAT'
�T\ 0
CITY/COMMUNITY/STATE/ZIP
JOB SITE ADDRESS/SPA-E
'rn) iC)
CITY/COMMUNIIITiTYY//((S_T�J�IIIAIT�E/ZIP •' ,
l...i-T • 1 A ,
BOK
PAG
PRC.
C
TN
PING
SE
S
TRACT
LOT
MOD
SB
TRACT NAME
OWNER NAME
(( /y Q-'•���
`5 LA 6 T-3- '
CONTRACTOR -FIRM NAME
C` ka�KAS� ONrnLr,c, t?cxol_S
ADDRESS
CITY/COMM\_T!'IT\TF`1'P����,�' f` i \ L �Ji C 1A '
PHON-2-4_W �/ f3V
�I/w��•�•1/�/�
1 / l/
'
ARC/ENG FIRM NAME
ADDRESS (( /
�a C
CITY/COMMUNITY/STATE/ZIP
PHONE I
LICNC 11
ERMIT�
USE OF PERMIT,--
BIL
BL
ZON
FSB
SSB
SSB
RSB
OFC
ZONE ORD I
LOT S2
END
$IDE
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 shallt,
,be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
0 thereby certifythatnoexcavation five (5)ormore feet indepth into Which aperson isrequired todescend,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 Title8,
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 has a permit to do such work from that division.
0 Division of Industrial Safety Permit No., r
Date Applicant
CONSTRUCTION LENDING AGENCY: I hereby affirm that'the-re 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
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 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
APPL/PRMT n 7 7 7 S DATE � 0 /
F/n 22 —� C, TT_
1 �1 1T —M> ,AJ—JT fq LL 75 ►
T�A_ V Che �V� GI�
Z Lam• c Ick i
-To-►� z- E- ��= Li -S Co
TOTAL
FEE
VALUATION 1319, rco
BLDG. DEPT.
1.
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.
❑
NOADDITIONAL INFORMATION
A�
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 .Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
126 Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING APPROVALS
13 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 PiI
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
298 Bonding
30 Fixtures
31 Service
32 Final