0666 (PLBG)r 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
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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 ($10D) 0, less. I certify that in the performance of the work,for which this permit is
(commencing with Section 7000) of Division Sof the Business and Professions Code, and my license is in lull force
::issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of
and effect.
California.
License Class Lic. Number
Date Applicant
Date Contractor -r„
;z NOTICE TO APPLICANT: If, after making this Certificate of Exemption,•you should become subject to the,Workers'
OWNER-BUILDER.DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for the°be
t, Compensation provisions of the Labor. Code, you must forthwith comply with such provisions or this permit shall
deemed revoked.
following reason (Sec. 7031.5. Business and Professions Code: Any city or, county which requires a permit to
- construct, alter, improve, demolish. or repair -any structure, prior to its issuance, also requires the applicant for
DIVISION OF INDUSTRIAL.SAFETY PERMIT CERTIFICATION:
such permit tofile asigned statement that heislicensed pursuant tothe provisions ofthe Contractor's License Law -'
,p IheiebyCertify thatnoexcavationfive (5)ormore feet indepth into which aperson isrequired todescend, will be.
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) or that he is exempt
made in connection with'work authorized by this permit, and that no building structure, scaffolding, falsework; or.
therefrom and the basis for the alleged exemption. Any violation of-$ection 7031.5 by any applicant for a permit
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341, Title8; .. .
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subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): :acrX?t,
C.A.C.)
O I, as owner of thepcoperty, or my employees with wages as their sole compensation, will do the work, and the
O 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. 7044, -Business and Professions Code: The Contractors 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, addwho does such work himself or
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through his'own employees. provided that such improvements are not intended or offered for sale. If, however, the
❑ Division of Industrial, Safety Permit No.
building orimprovemntissold within one year ofcompletion, the owner -builder will havethe burden of provingthat
Date Applicant
. he did not build or improve for the purpose of sate.):
CONSTRUCTION LENDING AGENCY: (hereby affirm that there is a construction lending agency for the performance
O I, 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
O 1 am exempt under Sec. B. 8 P.C. (Attached Certificate).
I certify that I have read Misapplication 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 .
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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
-END -.
certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. C.). a
Signature of Applicant or Agerit Date
Policy No. Company _
CERTIFICATE'OF,COMPLIANCEANDAUTHORIZATIONOFENTRY: Icertify Ihave read this applicationandstate that .. '
O Certified copy is hereby'furnished....-
the information given is correct. I agree to comply witt all state laws and county ordinances relating to buidling
O Certified copy is filed with the City Building Inspection Department or City Department.
construction;)6d authorize a' representative of tp !City of La Ouinta Department of Building and Safety to enter
'
Date Applicant
upon the propei:ty for wfiiC5lLI have applied•fa his per ohhe purpose of making' inspeotiiins.. {
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Signatures"of Applicant or Agent Date
APPLICANT NAME (L, F, Al) ,
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TRACT NAME
OWNER NAME (L. F. MI) �, k ALJ (, �• /�
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC N
ARC/ENG FIRM NAME -
ADDRESS
CITY/COMMUNITY/STATFJZIP
PHONE N
LICNC N
USE OF. PERMIT
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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 aPlenums & 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
10A
fireplace T.O.
❑
OWN
NO. ADDITIONAL INFORMATION
/
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SEWAGE SYSTEM SIZE & LOCATION.
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
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
29B Bonding
30 Fixtures
31 Service
32 Final