RPL (0327)PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
This permit becomes void it work not commenced within 160 days from date o1 issuance. OR, if work has been suspended or abandoned lot a period of 180 days.
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division Sol the Business and Professions Code, and my license is in lull force
and effect
License Class _1 Lic- Number
Date_ �� I+ —•—Contractor �!{�. L j / :.4
OWNER -BUILDER DECLARATION. I hereby affirm that I am 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, of 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 ohne Contractor's License Law
(Chapter 9 (commencing with section 7000) of Division Sof the Business and Professions Cade) or that he is exempt
therefrom and the basis for the alleged exemption. Any violation o1 Section 7031.5by any applicant lot a permit
subjects the applicant to a civil penally of not more than live hundred dollars (5500.):
D 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 of
through his own employees. provided that such improvements are not intended or offered for sale. It, however. the
building or improvemnt is sold w it hin 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.).
❑ I, as owner of the property, am exculsively contracting with licensed contractors td construct the project (Sec.
7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
builQs or improves thereon, and who contracts lot such projects with a contraclor(s) licensed pursuant to the
Contractor's License Law.).
❑ 1 am exempt under Sec. B. 8 P.C. (Attached Certificate).
Date Owner
-WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate o1 consent to sell -insure. or a
certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. Q.
Policy No. Company
D Certified copy is hereby furnished. -
O Certified copy is filed with the City Building Inspection Department or City Department.
Date Applicant
APPLICANT NAME (L. F. MI) —f n
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ADDRESS `.%(l— �Ic
/ ,70
CITY/COMMUNITY/ST/ATFJZIP
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JOB SITE ADDRESS/SPACE Sl' l E'
CITY/COMMUNITY/STATEIZIP <IAM F
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TOTAL
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TRACT NAME
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STA/T/EJZIP
PHONE I. // �„
LICNC I n
ARG/ENG FIRM NAME '
ADDRESS.
CITY/COMMUNITY/STATE/ZIP —
PHONEIII
LICNC I
USE OF PERMIT
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SSB
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RSB
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END
SIDE
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed it
the permit is tot one hundred (S100) o. less. I certify that in the perlotmance of the work for which this permit Is
issued. I shall not employ any person inany manner so as to become subject to the Workeis'Compensation Laws of
California.
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 1 hereby certify that no excavation five (5) of more feet in depth into which a person is required to descend. will be
made in connection with work authorized by this per mil, and that no building structure, scaffolding, falsework, or
demolition or dismantling thereof, will be more than thirty-six (36) feel high. (Chap 3.2, Grp 2. Art 2. Sec 341. Title 8.
C.A.C.)
O 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.
O Division of Industrial Safely 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 Addre
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 enicr upon the above-mentioned property for inspection purposes.
Signature of Applicant or Agent
CERTIFICATE OF COMPLIANCE AND AUTHORIZA7
the inloirriallon IjiSen is correct. I agree.to come
conslrudidn; and authbrize,a'repfej'entative of
upon the property for whichIl have applied fon
1i i" )J`_A1 1J, %
v ' `Signature of Applicant or Agent
Print Applicant/Agent Name
Date
ENTRY: I certify I have read this application and state that
all state laws and county ordinances relating to buidling
/ o1 La Ouinta Department o1 Building and Safety to enter
mit for the purpose of making inspectioniC:, `r
Dale
APPUPRMT}fr,�[`
-G 11,16 7-14<1: /%I
City of La Quinta
TOTAL
FEE
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VALUATION � =• •`'• ��=�
ASSESSOR