0851 (BLCK)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.
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 70001 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) of. 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 ($500.): '
0.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 or
through his own employees, provided that such improvements are not intended or offered for sale. If, however, the
building or i mprovemnt 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.).
0 I, 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 .
builgs or improves thereon, and who contracts lot such projects with a contractors) licensed pursuant to the
Contractor's License Law.).
.0 1 am exempt under Sec. 134 P.C'. (Attached Certificate). _
Date !� � r'' Owner
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self-insure,'or a
certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. Q.
Policy No. Company
O Certified copy.is hereby furnished.
0 Certified copy is filed with the City Building Inspection Department or City Department.
I Date Applicant
APPLICANT NAME (L. F. MI) , '• � .�
ra :.I G i
-ADDRESS
CITY/COMMUNITY/STATE/ZIP )
IA I,-,-, "f,rt 9 a3t0v
JOB SITE ADDRESS/SPACE
CITY/COMMUNITY/STATE/ZIP
t•. r, WL.1 ,, k r. •
BOK
PAG
PRC `
C
TWN
FIND
SE
S
TRACT
LOT
MOD
SB
TRACT NAME
OWNER NAME (L. F. MI) ,
CONTRACTOR -FIRM NAME '
ADDRESS -
CITY/COMMUNITY/STATE/ZIP
PHONE t
LICNC •
-
AO
ARC/ENG FIRM NAME l • .L
v
ADDRESS i
CITY/COMMUNITY/STATE/ZIP '
PHONE II
LICNC M
USE OF PERMIT ) t iA`` \j -
, Y,t Y1 lf. /C. t I
81.
r
ZON
TOTAL
FEE
FSB
SSB
SSB
RSB '
OFC
ZONE ORD M•••. ••..
LOT SZ
END
' SIDE
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed it
- 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' Compensation Laws of
California.
Date Applicant
NOTICE TO APPLICANT: IL 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:
0 I hereby certify that no excavation five (5) or'mdre feet in depth into whicti-a person is required to descend, will be
made in connection with work authorized b)i 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, TitleB;
C.A.C.) : y
0 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.
0 Division of Industrial Safety Permit No. /r
Date .7 . / 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 Address
z 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 AUTHORIZATIOWOF 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, and 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 thiiss'per'mit. for the purpose of making inspections.
Signature of Applicant ot!ligeni Date
l •. v , a e,
Print Applicant/Agent Name r /
APPL/PRMT1 1 !
DATE J •. '
1 C f i'�•i v�
f c> �t l y
IOU
Y
Jai,
r
14--i 1775
1.50
r
TOTAL
FEE
BLDG. DEPT.
VALUATION ���
NO.
OPERAT:ION� DATE
INSPECTOR
NO.
OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs &• Frms
7
34
Plenums & Ducts
2A
Slab Grade
35
Furnace Compart.
3
Steel
36
Inlets&.Outlets°'
4
Grout Blocks
37
Combustion Air
5.
Bond.Seams .
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
t0A•
Fireplace T.O.
❑
NON
ADDITIONAL 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
1.9 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 P/L
STREET NAME
26 Power Pole
27 Conduit
28, Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
3.1 Service
32; Final
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