COMB (0357)" PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety vv
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
• CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
' LICENSEDCONTRACTORS 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 -
,tcommencing with Section 7000) of Division 3 of the Business and Profenions Code.and'my'license is in full force
'issued. I shall not employ any person in any manner so asto become subject tothe Workers'Compensation Laws of
and effect.
California. 4 6; 1 '
- License Class Lic: Number
Date Applicant "
•Date '• Contractor, ''
NOTICE ••iO APPLICANT:.If: alter,making this Certificate of Exemption, you should become subject to the Workers'. ;
OWNER -BUILDER DECLARATION: I hereby affirm coat 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 ..
.be deemed revoked: .
following reason (Sec. 7031.5. Business and Professions Code:'Any city. or county which requires a permit to
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• construct, alter; improve:' demolish, orrepairany structure, prior to its'issuance, also requires the applicant.for
A'
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: -.
• such per mitto file a sig ned statement that he is licensed pursuant to,the provisions of the Contractor's License Law :;'
};O therebycertify fhatnoexcavationfiGe(5)ormoreleetindepthinto which apersonisrequired todescend,will be"
(Chapter 9(commencing:with section 7000)'of Division 3 of the Business and Professions Code) orthat 'he isexempt •
made in connection with work'authorized by this permit; and that no building structure: scaffolding, falsework; or. :
therefrom and the basis.for the alleged exemption. Any violation of,Section 7031.5 by.any applicant fora permit 'demolition or dismantlingithereof; will be more than thirty-six (36) feet high. (Chap 3.2. Gip'2r Art 2,,Sec 341. Title 8. .
subjects the applicant to'a.civil penalty of not more than five•hundred dollars ($500.):
C A C.I°a G h
-:.0 I, as owner of the property. or_my employees. with wagesas their.sole compensation, will do the work, and the . -
. '0 As owner-tiuilder,' P will not employ anyone to do -work which would'require a permit4rom 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•srich 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 employees, provided thaosuch improvements are not intended or offered for sale: If; however, the ..
O Division,of Industrial Safety Permd,No. n
building orimprovemntissold within one year ofcompletion, the owner -builder will have the burden of proving that'.... .:"'Date"
- Applicant.
- he did not build or -improve for the purpose of sale.). z =
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agencyfor the performance
0 I, as.owner:of the property, am ekculsivefy 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'
'builds
Lender's Name
or•irnproves thereon; and who contracts for such projects with a'contractor(s)'licensed.pursuant to
RSB
' Contractor's License Law.):
Lender's Address
'a
0 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, .
'f
' Date Owner " 4 4r
_ city and county ordinances and state laws relating to building construction, and hereby authorize representatives.
oithfs county to enter upon the above-mentioned property for inspection purposes. '
' WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure. or a►� .•," r -
certificate of Workers' Compensation Insurance , or a certified copy thereof. (Sec: 3800. Lab: C:):
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 alfstate laws and county ordinances relating to buidling
' 0 Certified copy is.filed With -the City Building Inspection Department or Oft ." ' Department. '•
✓ -c ; 5 1j !!!!!! j -
Date o t! Aft �`�%d�,d ae�/,�. ��.✓i�
construction, and authorize-a'representative of1the 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:,
plicant-'' ~�
�s
i
Signature of Applicant or Agent Date
Print Applicant/Agent Name •.
,S
APP/CCANT��yHyAAME (L¢nF. MI)
ADDRESS -
CI�COM MUNI�s�i���-
JOB SITE ADDRESS/SPACE ... ..
CITY//CCOO�MMMUUNNIpTY/STATE21P-
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TRACT NAME • • -
OWNER NAME (L. F. MI� -
CONTRACTOR -FIRM AAASodNAM 0d
'ADDRESS
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CITY/COMMUNITY/STATE/ZIP l \1 Su 'E/Z1/� ` /_ Ci /Y �li5
PHONE • ✓. �� ! `
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'job / ♦f ! ,
ARC/ENG FIRM NAME -
ADDRESS �fj•='
CITY/COMMUNITY/STATE/ZIP - ^
PHONE11
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UCNC
USE OF PERMIT
BL
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FSB :
SSB
SSB
RSB
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'ZONE ORD �,
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LOT Sr •�
- END
- .SIDE -
VALUATION
BLDG. DEPT.
mini .s-3100.7- a.�
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'TOTAL'-*
FEE
� 4
VALUATION
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 / 3m 8
x"�
35
Furnace Compart.
3
Steel Pjq �YoU193
-
36
Inlets 8i Outlets
4
Grout Blocks
37
Combustion Air
5
Bond Beams 3
38
Compressor
6
Roof Deck
39
Appl. Clearance
7
Framing
40
Fire Damper
B
Vents
41
Smoke Detection Device
9
Garage Fire Wall
42
Commercial Hood
1'1)
Fireplace P. L. ❑
43
Final
1'0A
fireplace T.O. ❑
NADDITIONAL INFORMATION
O.
NO.
! �� ems, aQosa1
rf.�%�i'�st/��
/ / -
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A DrywallI
13 Finish Grade
INSULATION Thick R"
Value
7A Walls (Batts) ?
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING APPROVALS
15 Ground Plumb
1$ 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 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