0329 (PLBG)PERMIT APPLICATION
City of La Duinta
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:
• �' .. -
-CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
LICENSED CONTRACTORS DECLARATION: I hereby affirm" that 1 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)'ol Division 3 of the Business and Professions Code, and my license is in full force
issued. I shall.not employ any person in any manner so as to become subject to the Workers'Compensation Laws of
and effect.
California.
License Class Lic. Number
Date Applicant
' Date! M" Contractor -
NOTICE TO APPLICANT: If, after making this'Certificate of Exemption, you should become subject to the Workers'
^ 'ARATION: v I hereby affirm that I am exempt from the Contractor's License Law forthe
OWNER -BUILDER DECL
Compensation provisions of the Labor Code, you must forthwith comply with such provisions onthis permit shall
- -
following reason (Sec. 7031:5, Business and Professions Code: Any city or county which requires a.permit-lo
be deemed revoked.
construct, alter, improve,•demolish, or repair any structure, prior to its issuance, also requires -the applicant for ,.
DIVISION.OF,INDUSTRIAL SAFETY PERMIT CERTIFICATION:
such permit -to file a signed statement thathe is licensed pursuant to the,provisions of the Contractor's License Law -'
.11 1 hereby ceitify thit no excavation five (5) or more feet in depth into which a persoh is required to descend. will be
"(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) or that he is exempt - '
made -in connection with work authoriied by this permit; and that no buildiiig structure, scaffolding, falsework, or
therefrom and,Ihe basis for the alleged exemption: Any violation of Section 7031.5 by any applicant for a permit
demofition or dismantling thereof, will.be more than thirty-six (36) feet -high. (Chap 3.2; Grp".2, Ai 2; Sec341, Titlefl. •
subjects the'applicant to a civil penalty of not more than five hundred dollars ($500.): • -^
C.A.C.) _ . . • - r -M `'-,
O L.as owner of the property, or my employees with wages.as their sole compensation, will do the work:and the : ;
r • O'As owner-builder,'t.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 Contractors License .. -
- ° Industrial Safety, as -noted above: unless such peisorrhas a permit to do such .work from that division.
Law does not apply to_an oner of property who builds, or improves thereon; and who does such work himself or . -
- . . • I
through his own employees, provided that such improvements are not intended or offered for sale: IL'however, the'. '
O Division of Industrial Safety -Permit No.
build ing or i mprovemnt is sold within. one year of completion, the owner -builder wil.1 have the burden of proving that
Date Applicant
he did not build or. improve for the purpose of sale:). _
CONSTRUCTION LENDING AGENCY: I hereoy affirm that there is a construction lending agency for the performance
Qs�s owner of the property, am exculsively contracting with licensed contractors to construct the project(Sec.
'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
RSB
Contractor's License Law.). _
Lender's Address
❑ Faln.exempt under Sec.'p �'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 '
' Date Ownery✓
cityand county ordinances and state laws relating to building construction, and hereby authorize representatives ..
'WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have, certdlcate of consent to self -insure -or a
of this county to enter upon the above-mentioned'property for inspection purposes. '
certificate of Workers' Compensation Insurance . or a certified copyereof.(Sec. 3800. Lab. C.)r' ' `:
Signature of Applicant or Agent -,Date
Policy No. Company
•. �
"CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY Icertify thave read this application and state thaP.:'
O Certified copy.is hereby furnished: v
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
❑ Certified copy is tiled with the City•Building Inspection Department of City Department.
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.
Date Applicant
Signature of Applicant or Agent Date
APPLI ANT NAME (L, F, MI)
�H/Y�iS sib.. -d .JAII,I�
�ADDRESS'
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CIT /COMMUNITY/STATE/ZIP •.. -
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JOB SIT}}E^ADDRESS/I/SPACE
CITY/COMMUNITY/STATE/LIP
BOK
PAG
PRC
C'
TWN
RNG
SE-
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TRACT
LOT
TOTAL • '
• FEE •
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MOD
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-
TRACT NAME -.
OWNER NAME (L. F. MI) .�
CONTRACTOR -FIRM NAME '
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHO�
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LICNC •
ARC/ENG FIRM NAME
-ADDRESS
'CITY/COMMUNITY/STATFJZIP - - ..
'PHONE •
LICNC I
..
USE OF PERMIT
BL
ZON
FSB
SSB
SSB
RSB
OFC
ZONE ORD • -
LOT SZ'
END
Print Applicant/Agent Name
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city of La Quinta
TOTAL • '
• FEE •
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BLDG. DEPT. VALUATION
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NO.
OPERATION' DATE
INSPECTOR
NO.
OPERATION DATE" INSPECTOPk
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back .
33
Ventilation System
2
Ftgs & Frms
34
Plenums & Ducts
2A
Slab Grade
35
Furnace Compart.
3
Steel
36•
Inlets & 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.
0
43
Final
10A
fireplace T.O. ❑
N
NO.
O.
11
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
19 Sewage Disposal
20 Sewer /0 7 A L �,QG�SI
21 Water Heater
22 Water Softener
23 Water Service
24 Gas Test
25 Final
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
P/L P/1
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
290 Bonding
30 Fixtures
31 Service
32 Final
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