0314 (SFD)'PERMIT APPLICATION , •�J �� • f� , , . y� a ' +
City
of La Ouinta
Department of Building and Safety .
+ This permit becomes.void it work not commenced within .180 days from date of issuance, OR, it work has been suspended or abandoned fora period of.180 days.
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- CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATIONINSURANCE:Thissseclio�n,neednotbecompletedif
.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 in any manner so as to become subject to the Workers'CompensationLaws of .
and effect.
CalifoT.
z
License Class ` Lic. Number
Vale / Applicant'��
Date• ' / Contractor--
NOTICE TO APPLICANT: If, after making this Certificate of.Exemption,you should become subject to the Workers'
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OWNER -BUILDER DECLARATION: I hereby affirm that Lam exempt from the Contractor's License Law for theme
+. Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall
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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 state mentthat heislicensed pursuantto:theprovisions ofthe Contractor's License Law
- OIhereby certifythaPnoexcavation. five (5)ormore feet indepth .into w6chaperson 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 idconnection with work authorized by this petmil, and that no building structure, scaffolding, talsework, or
therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit ..
demolition or dismantling thereof, will be more than thirty-six (38) feet high. (Chap 3.2, Grp 2, Art 2, Sec341, TItle8,
• subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): a sa:
C.A.C.) r/
.0 [Pas owner of the property, 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 Contractor's License
Industrial Safety, as noted above, unless such' person has a permitto 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 orr
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through his own employees, provided that such improvements are not intended oroffered for sale: If, however, the
have the burden that.
0 Division of Industrial Safety Permit No. ✓
• ! F-
Date '�
,buildingorim rovemntissoldwithinone year ofcom completion, will of proving
P Y D D 9
_Applicant:
v
• he did not build or improve for the purpose of sale.).
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CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
❑ 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 Contractors License Law does not apply to an owner of property who
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I. builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to -the :.-
Lender's Name
. .
,Contractor's License Law.). • -,
r_: Lender's Address
❑ 1 am exempt under Sec. . B. & P.C. (Attached.Certificate).
.. I certify that I have read this application and slate that the above information is correct. I.agree to comply with all . ,
Date " "' Oviner
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, ora
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 l have read this application and state that
- ❑ Certified copy is hereby furnished.
(:' • 4he information given is correct. I agree to complywith all state laws and county ordinances relating to buidling
O Certified copy is filed with the City Building Inspection Department or City Department. ;
$; .copstruction,.and authorize a' representative of the City of La Ouinta Department of Building and Safety to enter •,
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upon the property for which-Chave applied for this permit for the purpose of making inspections. -
Date Applicant
Signature of Applicant or Agent Date
APPLICANT NAME (L. F. MI) '
PA 6 i. 's / 4 G-
ADDRESS, _ •'"�
CITY/COMMUNITY/STATE/ZIP 2 /-•A
JOB SITE _RES 4) ' OVEN
J �7
E N I PACITY/COMMUN
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kA QItfi ,J -r,4 0_ /i (I 7 4 7
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PAG
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TRACT
LOT e
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TRACT NAME
OWNER NAME (L. F. MI) •-
CONTRACTOR -FIRM NAME _ .. •• - '
ADDRESS '
CITY/COMMUNITY/STATE/ZIP •' -, ..
PHONE •. '
LICNC a-
ARC/ENG FIRM NAME . 4.
ADDRESS
CITY/COMMUNITY/STATE/ZIP - - - -
PHONE • -
LICNC 8
-
USE OF PERMIT '
BL
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FSB
SSB
SSB
RSB
OFC
- ZONE ORD 11, ..
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END -."
SIDE'
Print Applicant/Agent Name
APPUPRMT , n1.1-4 kT o.3 '
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'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
�o ,?
35
Furnace Compart.
3
Steel
36
Inlets & Outlets
4
Grout Blocks .
37
Combustion Air
5
Bond Beams
38
Compressor
6
Roof Deck
3
39
Appl. Clearance
7
Framing
i
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.
❑
OP'NO. ADDITIONAL INFORMATION'
�i
Al"ST
;
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick Value
7A Walls (Batts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING APPROVALS
15 Ground Plumb ZLM 7-A
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
298 Bonding
30 Fixtures
31 Service
32 Final
S°�L-