0210 (SFD)PERMIT APPLICATION
City of La Ouinta
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.
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division Sof the Business and Professions Code, and my license is in full force
and effect.
License Class
Date Contractor
Lic. Number
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 live hundred dollars ($500.):
O 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 improvemnt 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 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
builps or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the
Contractor's License Law.).
0 1 am exempt under Sec. . B. 8 P.C. (Attached Certificate).
Date Owner `" `rte r�
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a ce4ificate of consent to self -insure, or a
certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. C.).
Policy No. Company
❑ Certified copy is hereby furnished.
❑ Certified_ copy is filed with the City Building Inspection Department or City Department.
k
Date / Applicant
APPLICANT NAME (L. F. MI) ,c�� d
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CITY/COMMUNITY/STATE/ZI P
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JOB SITE ADD
CITY/COMMUNITY/STATE/ZIP
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TRACT I
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TRACT NAME
OWNER NAME (L, F. MI) /w
CONTRACTOR -FIRM NAME
'ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC N
Qom, 79
TOTAL
FEE
ARC/ENG FIRM NAME v
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC N
USE OF PERMIT
BL
ZON
FSB
SSB
SSB
RSB
OFC
ZONE ORD N
1
LOT SZ
END
SIDE
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
the permit is for one hundred (3100) o, less. I certify that in the performance of the work for which this permit is
issued, I shall not employ any person i n any manner so as to become subject to the Workers' 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) 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, talsework, or
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2. Art 2. Sec 341, Title 8.
C.A.C.)
❑ 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.
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 Address
I certify that I have read Misapplication 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, 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 this permit for the purpose of making inspections.
Signature of Applicant or Agent Date
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,/Print Applicant/Agent Name
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0i La Quinta
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TOTAL
FEE
VALUATIONS•3�
Arrow Printing 250/1;83 White: Finance Canary: Assessor `Pink Applicant • Tag: Bldg. Dept.
NO.
Ground Plumb
OPERATION' DATE
Water Piping
17
BUILDING APPROVALS
1
Set Back
19
2
Ftgs & Frms
Sewer
2A
Slab Grade
22
3
Steel
Water Service
4
Grout Blocks
25
5
Bond Beams
6
Roof Deck
7
Framing
/0
8
Vents
9
Garage Fire Wall
10
Fireplace P. L.
❑
10A
Fireplace T.O.
❑
11
Exterior Lath
12
Internal Lath
12A
Drywall
13
Finish Grade
INSULATION
Thick R
Value
7A
Walls (Batts)
126
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
ELECTRIC APPROVALS
26 Power, Pole
27 Conduit
28 Service Entrance
29 ' Wiring, %Q
29A Grounding. Wire
29B Bonding
30 Fixtures
31 Service
32 Final
INSPECTOR NO. OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
33 Ventilation System
34 Plenums & Ducts
35 Furnace Compart.
36 Inlets & Outlets
37 Combustion Air
38 Compressor
39 Appl. Clearance
s 40 Fire Damper
41 Smoke Detection Device
42 Commercial Hood
43 Final
NON ADDITIONAL INFORMATION SS
L
T1�,�
SEWAGE SYSTEM SIZE & LOCATION
Tank Pit L. Line
STREET NAME
REAR OF PROPERTY LINE
P/L