0742 (RPL)S;., .
• PERMIT APPLICATION
City of La
Ouinta
Department of Building
and Safety
BOK
PAG.
This permit becomes void if work not commenced within -180 days from.date of issuance; OR, if. work has.been suspended or abandoned for a period of 180 days. :.
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CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE:. This section need not be completed it
`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 I.nanymanner so alto become subjectto the Workers'CompensationLaws of ,
and effect.
California. ,
License Class, - Lic: Number. ....
..Date Applicant .,
Date Contractor s
: NOTICE TO APPLICANT, If, afte.rmaking this Certificate of Exemption, you should become subject to the Workers' ..
OWNER BUILDER DECLARATION:, l hereby affirm that.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
- following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires,a permit to
be deemed revokedt„
construct,.alter, improve: demolish, or repair any structure' prior to its issuance; also requires the applicant for
. DIVISION.OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
,••such, per mil.to.,file a signed statement that he is licensed pursuant to the provisions of the Contractor's License L aw`-0
1 hiereby'cerlify that no excavation five (5) or more feet in depth into*hicli a person is required to descend, will be
(Chapter 9(commencing with section 7000).of Division 3 of the Business and Professions Code) orthat he is exempt : ,.
made'in connection wit h'work authorized 'by this permit, and that no building structure, scaffolding, Ialsework, or,..-.
therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any. applicant for a permit ,
demolition or dismantling thereof, will be more than thirty-six (36) feet high:•(Chap 3.2. Grp 2, Art 2; Sec341, Title8,
subjects the applicant to a civil penalty of not more thanfive•hundred dollars ($500.):
C.A.C.)
O 1. as owner of.the property, or my employees.with Wages astheir.sole compensation, will do the work, and the
0 As owner -builder, I will not employ anyone to do work which would require a.permit from the Division of '
structure is not intended or offered for sale (Sec: 7044, .Business and Professions Code: The Contractor's License'
. fnCustrial Safety, as noted above, unless such person has a permit to do such work from that division'
/ Law does not apply io 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 intendedbnoflered for sale. If, however, the , _
❑Division of Industrial Safety Permit. No.
.building or imp[ovemnt is sold within one year of completion. the own.er-builder will have the burden of proving that.
Date "-^Applicant
he did not build;or.improve for the purpose of sale.)
CONSTRUCTION LENDING AGENCY: 'I hereby affirm that there is a construction lending agenWf6r the performance '
0 I, as owner of-the,property, am exculsively contracting with licensed contractors.to construct the project (Seca.
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
Lender's Name
builds or improves thereon, and who contracts for such projects with a,contractor(s) licensed pursuant to the
„
Contractor's License Law.):
Lender's.Address '
0 Lam ex/empt under Sec. - •• ' i - 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 . • . -..
x'
Date; r�� '�� d ! Owner w ' '/'"I, ' ?�
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
_ �°�'
' s v
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
. , . . , . .-
certificate of Workers''Compensation Insurance, ora'certified copy thereof (Sec. 3800. Lab: C.). -.
:. Signature of Applicant or Agent Date
Policy No. Company
CERTIFICATE, OF COMPLIANCE AND AUTHORIZATION: OF (certify (have read thisapplicalionand 'statethat
0 Certified copyris hereby furnished.- '
the information given is correct. I agree to:comply*Ih all state laws and county ordinances relating to buidling
0 Certified copy is filed with tfie'City Building Inspection Department or City - Department. ":
construction, and authorize a'representative of the City of La Ouinta Department of Building and Safety to enter
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upon the property for.which 1 have applied (or' this permit for the. purpose of making inspections. _.
Date Applicant.
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Signature of Applicant or Agent _ Date
APPLIC qNT NAME (L. F: -MI) • ,
_
ADDRESS' - -•
CIT Y//COMMMUUNNIIT�Y//STATE/ZIP
JOB SITE AODRESS/SPACE • .. - , .
CITY/COMMUNITY/STATE/ZIP -
BOK
PAG.
PRC •.
C
"• ' ' •
TWN
FIND
SE
.'S
TRACT
LOT
TOTAL
FEE
MOD
SB.
TRACT NAME•
OWNER NAME.(L, F. MI)
CONTRACTOR -FIRM NAME - •• - . .
ADDRESS,
CITY/COMMUNITY/STATE/ZIP
1
PHONE •
_�14151r/ el `•
LICNC 4
'
ARC/ENG FIRM NAME
ADDRESS .. -
CITY/COMMUNITY/STATE/ZIP -
PHONE* -
LICNC••
..
USE OF PERMIT
BL
ZON
FSB
/ SSB
SSB
RSB
•' ZONE ORD,* -
-LOT SZ
END
SIDE- ,-
Print Applicant/Agent Name
APPL/PRMT 7 4 X DATE
lof`& i1 IS
ee
OF
TOTAL
FEE
VALUATION
RLDG.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
36Inlets & 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
'
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
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 r'
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
PSL PiI
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final