0488 (RC)PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
This permit becomes void if work not commenced within 180 days from,dale 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 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 issued; I shall not employ any person inanymannersoasto become subject to the Workers'Compensation Laws of
and effect. - /`i California.
.License Class Lic..Number Yl3 Date Applicant •
Date%=� , Contractor. X�� ��5 %- I NOTICE TO APPLICANT: If, after making this Certificateof Exemption, you should become subject -to the Workers'
OWNER -BUILDER DECLARATION: I.hereby affirm that I am exempt from the Contractor's License taw 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 signedstatementthat heislicensed pursuantdothe provisions ofthe Contractor's License Law 17[hereby certify thatnoexcavation five (5)ormore feel indepth into which aperson isrequired todescend, 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 authorized by this permit, and that building structure• scaffolding, falsework, or
therefrom;and the -basis for the alleged exemption. Anyyiolation.of Section 7031.5 by.any applicant for.a permit demolition or dismantling thereof; will be more than thirty-six (36) feet high. (Chap 32,.Grp 2; Art 2, Sec 341, Title 8,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): C.A.C.)
❑ I. as owner of the property, or my employees with wages as their sole compensation, will,do the work, and the 1 O As ownerebuilder, 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. 7044, 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
through his own employees, provided that such improvements are not intended or offered for sale. If, however, the: 0 Division of Industrial Safety Permit No. t .
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.). 7 r.
CONSTRUCTION LENDING AGENCY-, I hereby affirm that there is a construction lending agency for the performance
O 1, as,owner of the property, am exculsivefy 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 contraclor(s) licensed pursuant to the T
Contractor's License Law.). ._ Lender's Address
,Dl I am exempt under Sec. - B. 8 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"Owner 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. .
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. C.).
~Signature!of Applicant or Agent Date
Policy No. Company 'CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
O Certified copy is hereby furnished.,. _ the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling .N
❑ Certified copy is filed with the City Building Inspection Department or 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
.•
APPLICANT (l,: FQ^M1)evp ^ A/S;rNo 04 TMvv
ADDRESS7 W -�J �`oV
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CITY/COMMUNITY/STATE/ZIP-. ..
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JOB SITE ADDRESS/SPACE -
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CITY/COMMUNITY/STATE/ZIP4;,;r,4 .
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TRACT
LOT
TOTAL
FEE
MOD
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TRACT NAME .-
OWNER NAME (L. F, MI) A961,14A +"•� Cf7�J /- �+�
CONTRACTOR�FIRRMJ NAM
ADDRESS _
CITY/COMMUNITY/STATE/ZIP
PHONE W-1 _ �D - /
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ARC/ENG FIRM NAME
ADDRESS -
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC 0
USE OF PERMIT
SL
ZONFSB
SSB
SSB
RSB
ZONE ORD Ik.
LOT SZ
• END
SIDE
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMT 0488DATE
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City of La "kiinta
TOTAL
FEE
BLDG. DEPT.
VALUATION I yeDO. OO
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
.1
Set Back
33
Ventilation System
2
Ftg"s & 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.
❑
43
Final
1.0A
Fireplace T.O.
❑
NON ADDITIONAL INFORMATION
-
V
SEWAGE SYSTEM SIZE & LOCATION
1 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
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/1
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire.
29B Bonding
30 Fixtures
31 Service
32 Final