SOL (0598)C.
PERMIT APPLICATION
City of La Ouinta
. Department of Building and Safety;
This permit becomes void it work not -commenced within 180 days from date of issuance,
OR, if work has been suspended or abandoned for a period of 180 days.
JOB SITE AODRESS/SPACE -
CERTIFICATE OF EXEMPTION FR06VORKERSCOMPENSATION INSURANCE: This section need not be completed it..; .
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9. '.c
.'the permit is for one hundred, ($100) o, less..l 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. '/ ly U G / <
r_4,410
California.
License Class// / Lic. Number ' _,
tom/ /�^-/- 4- t%�?.;,ys .J/ •..-/. �'/J ie? SGS, ..
'
.Date Applicant -
Date Contractor: - r
NOTICE TO APPLICANT; If, after making this Certificate aLExemption,:you should become subject to the Workers' .:
' OWNER-BUILOER.DECLARATION: I hereby affirm that I' am'ezempt, Iron the Ceni'ractor'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 of the Contractor's License Law -• :.
0 1 hereby certify that n o excavation five (5) or more feet in depth into which a person is required to descend, will be
_. (Chapter.9(commencjng wtthsection 7000) of Division 3 of the Business and Professions Code)or that he is exempt;
made in connection with work authorized by this permit; and that no building structure, scaffolding, falsew ork, or
therefrom and the basis for,the alleged exemption. Any violation_ol.,Section 7031.5 by any applicant fora permit ,
< .demolition or dismantling thereof; will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2r Art 2, Sec341, Title B, .
subjects the applicant to a civil penalty of not more thamfive lliundred do0ars ($500.):
C.A.C.)
• 0 t 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: tb do work ,which would require a permit from the Division of '
structure is not intended or offered for sale IS 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
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through his own employees: provided that such improvements are not intended or offered for sale., 11, however, the ,,
Oivisfon of.Industrial.Safety.Permit No,
building or.improvemnt is sold within one year of completion, the owner -builder will.have the burden of provingthat
Date Applicant
he did not build or improve;lor the purpose of sale.).
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency:for the performance .
0.1; as owner of the property.°am exculsively contracting with licensed contractors.to construct the project (Sec: ...,.
of.the work fokwhich 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 contracts4or such projects with a contractor(s) licensed pursuant ito the
Contractor's License law.).
Lender's Address
0 1 am.exempt under Sec-- - B:•8 P.C. (Attached Certificate):
41' 444
(,certify that I have read.this application and state that the above information is correct.I agree to comply with all
city and couniy,ordinancesond state laws relating to building construction, and hereby authorize representatives... • .
Date' OwnerC�_,nEf
.
of this 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
SIDE
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certificate of Workers' Compensation Insurance , ora certified copy thereof (Sec. 3800. Lab. C.)..'
Signature of Applicant of Agent Date
Policy No. Company.
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
❑ Certified copy, is.hereby furnished:, r✓'; , - rr, ..
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the information given is correct. I agree to com I .with all state laws and count ordinances relating to buidlin . '
9 9 DY Y 9 0
- 0 Certified copy is filed with the City Building Inspection•Department,or Cdy , :• -!Department. -;
construction, and authorize a,'representative of the City of La Ouinta Department.of Building.and Safety-to.enter
t 4/ / \ . - ` ' ' .
`- •
•• 'upon the=property for:wfiich l have applied for this permit for,the purpose of making inspections.'
Date Applicant;-���
- - , . : ' „•.:.
,,Signature�ftApplican't or Agent Date
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Print Applicant/Agent Name
'APPLICANT -NAME (L, F,.MQ -
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ADDRESS - SYS /y1 V A_tr6W 0
CITY/COMMUNIT.Y/STATVZIP
JOB SITE AODRESS/SPACE -
CITY/COMMUNITY/STATE/ZIP • -
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TRACT NAME
OWNER.NAM`E,•t(L`4i"k:: •• •..
CONTRACTOR -FIRM NAME
ADDRESS _ /f'j)� C 2_7 CrQ
.CITY/COMMUNITY/STATE/ZIPPH
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ARC/ENG FIRM NAME - ... - - •.
ADDRESS
CITY/COMMUNITY/STATE/ZIP • • -
PHONE N -
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LICNC
USE OF PERMIT -
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VALUATIONCJ
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. .. - TOTAL.
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VALUATIONCJ
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
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
3
Vents
41
Smoke Detection Device
9Garage
Fire Wall
42
Commercial Hood
10
Fireplace P. L.
❑
43
Final
10A
Fireplace T.O.
❑
NON
ADDITIONAL INFORMATION
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick V al
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
P/L P/1
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final