0755 (SPIN)PERMIT APPLICATION z,(
City of La Ouinta
Department of Building and Safety
r : This permit becomes void i1 work not.commenced within 180 days from date of,issuance. OR,•If'work has been suspended or abandoned for period of 180 days:
ADDRESS
72r - 3?/ 14,av/��
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
" 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 '.
r issued, I shall not employ any person in anymannerso as'to become subject to the Workers' Compensation Laws of
and effect.
California.
License Class Lic. Number
Date Applicant
'Date. Contractor
NOTICE TO APPLICANT: If, after making this Certificate -of Exemption, you should become subject to the Workers' '
OWNER -BUILDER DECLARATION: I hereby alfirm that Fam �exempClrom 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 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 that he is.licensed.pursuant to the provisions of the Contra , ctor's License Law -
OIhereby certifythat noexcavationfive(5)ormore feet indepth'intowhich apersonisrequired teidescend,will be
(Chapter 9(commencing with section 7000) of Division 3 of the Business and Professions Code) orthat he is exempt.
made in connection with work authorized by this permit; and that no building structure, scaffolding, falsework, or
therefrom and the basis for the alleged exemption. Anyviolation of Section 7031:5 by,any applicant for a permit
demolition or dismantling thereof, will be_more ilian thirty-six (36) feet high: (Chap 3.2• Grp 2, Art 2, Sec341, Title B:
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
C.A.C.)
• O Las owner of the property: ormy employees with'wages as their sole compensation, will do the work, and the
- ❑ 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: 7844. Business and Professions Code: The Contractor's License '
Industrial Safety, as noted above, unless such person has a permit to do such work from that division.
Law does not apply to an owner of property who builds, or improves thereon, and who does such work himself or. +
CITY/COMMUNITY/STATE/ZIP
through his own employees, provided that such improvements are not intended or offered for sale=lf, however, the
O Division of Industrial Safety Permit No;
building orimprovemntissold within one year ofcompletion, the owner -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 agency for the performance
O 1, as 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
SSB
Contractor's License Law.).
Lender's Address
OFC
' O 1 am exempt under Sec. �"" B: 8 P.C. (Attached Certificate). '
• I certify that I have read this application and state that the above information correct. I agree to comply with all
�: z/- �•• / r+'' =� �p
y Owner
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
,Date
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 or a certified copy thereof (Sec 3800 Lab;.0 ) '
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) '
ADDRESS
72r - 3?/ 14,av/��
CITY/COMMUNITY/STATFJZIP
C) ,4 f?
JOB SITE ADDRESS/SPACE
7A -
CITY/COMMUNITY/STATE/ZIP '
BOK
PAG
'PRC
' C
RNG
SE
S
TRACT
LOT
r ... TOTAL
FEE
M
E-S
TRACT NAME
OWNER NAME (L. F. MI) ..
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE I1 -
LICNC I
ARC/ENG FIRM NAME '•
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE I1
LICNC o
.•
USE OF PERMIT
BL
ZON
FSB
SS8
SSB
RSB
OFC
ZONE ORD.•'LOT
SZ•.
END
.SIDE
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
Print Applicant/Agent Name
Date
APPVPRMT � � b1 � to /� X 7 �`" �� •
r ... TOTAL
FEE
:—
VALUATION
BLDG. 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
36
Inlets & Outlets
4
Grout Blocks
37
Combustion Air
5
Bond Beams
38
Compressor
6
Roof Deck
39
Appl. Clearance L
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. Cl
NON ADDITIONAL INFORMATION
(
Iq
,
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
1$ ' Vents
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
P/L P/I
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
298 Bonding
30, Fixtures
31 Service
32_ Final