0842 (AR)I PERMIT APPLICATION
City of La Duinta
Department of Building and Safety
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.
t.
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of•Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force
and effect.
License Class Lic. Number
Date Contractor
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, or 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 of the Contractor's License Law
(Chapter 9 (commencing with section 7000) o1 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 (5500.):
`O I. as owner of the property. o6,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 i mprovemni 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.).
O 1, 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.).
O 1 am exempt under Sec. - B.-6 P.C. (Attached CeiJticate).
Date �•' �/ .. / k / '6wner' f✓ r.t - ;E^*^�.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I havea certificate of consent to self -insure, or a
' certificate'of Workers' Compensation Insurance.1,or a certified copy thereof (Sec. 3800. Lab. C.).
Policy No. Company
0 Certified copy is hereby furnished.
❑ Certified copy is filed with the City Building Inspection Department or City Department.
Date Applicant
APPLICANT NAME (L. F, MI)
ADDS _ '9 77
IITY/COMM MMUN ITY/STA�TE//Z'I PP
CITY/COMMUNITY/STATE/ZIP
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JOB SITE ADDRESS/SPACE -
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City of la .Quinta
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TRACT NAME -
OWNER NAME (L. F, MI) .� ..
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CONTRACTOR -FIRM NAME, -
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE •
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LICNC
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ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 0
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,LICNC •
USE OF PERMIT
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RSB
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END
SIDE
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
the permit is for one hundred ($100) o, less. I certify that in the performance of the work for which this permit is
issued, I shall not employ any person in any manner so as to become subject to the Workers.Compensalion Laws of.
California. T i
Date 7 / ' / Applicant e' a ^� / /— ,
—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'INDI.STRIAL SAFETY PERMIT CERTIFICATION: ,
❑ 1 hereby c erlity that no excavation five (51 or more feet in depth into.which a person is required to descend, 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,
,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.
❑ Division of Industrial, Safety Permit No. r'
Date r / Applicant X/
CONSTRUCTION LENDINGAGENCY: 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.). i
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,zand 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
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City of la .Quinta
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NO.
OPERATION DATE INSPECTOR
NO.
OPERATION DATE INSPECTOR T
SUIL•DINGAPPROVALS
MECHANICAL APPR.OVA 9.
1.
Set -Back
33
'Ventilation System
2'
Ftgs & Frms
34
Plenums &.Ducts
2A
Slab Grade
35
Furnace Compact.,
3
Steel
36
Inlets&Outlets
4
Grout Blocks
37
Combustion Air
5.
Bond Beams
38
Compressor
6
Roof Deck
7
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:
❑
OP'NO.
ADDITIONAL INFORMATION
f1
/
D
SEWAGE SYSTEM.SIZE:&,LO.CATION.
11 Exterior Lath pts
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION. Thick Value
-7A Walls (Batts)
12B Ceiling (Batts)
12C Ceiling,(Blown)
14 Final
-PLUMBING APP OVALS
15 Ground Plumb
16 Water Piping
17 Rough Plumb '
18 Vents
19 Sewage Disposal .. D
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 PSL
'
STREET'NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring...
29A Grounding Wire
29B. Bonding
30 Fixtures
31 Service
32 Final