0024 (BLCK)PERMIT APPLICATION, '
City of La Ouinta
r Department of Build ng 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
CERTIFICATE OF EXEMPTION FROM WORKERS'COMP
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9
(commencing. with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force
and effect:
License Class Lic. Number
Date Contractor
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for the
following reason (Sec. 7031:5: Business and Professions Code: Any city or county which requires a permit-
lo—construct. alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for"
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law -
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) of that he is exempt"
therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars (5500.):
O I, as owner o1 the property, or my employees with wages as their sole compensation, will do the work, and the
structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License "
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
building or improvemnt is sold within one year of completion, the owner-builder"will have the burden of proving that
he did not build or improve for the purpose of sale.).
O I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec.
7044, Business and.Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the
Contractor's License Law.).
O 1 am exempt under Sec. B. 8 P.C. (Attached Certificate).
Date Owner
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.).
Policy No. Company
O Certified copy is hereby furnished.
O Certified copy is filed with the City Building Inspection Department or City Department.
Date Applicant
APPLICANT,NAME (U F. MI)
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ADDRESS I
S. � — it 00'e& , /0
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CITY/COMMUNITY/STATE/ZIP
JOB SITE ADDRESS/SPACE y
-;, rem •-
CITY/COMMUNITY/STATE/ZIP
BOK
PAG
PRC
C
TWN
RNG
SE
S
TRACT
LOT
TOTAL
FEE
MOD
SB
TRACT NAME
OWNER NAME (L. F, MI)
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP ,
PHONE N
LICNC N
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC N
USE OF PERMIT
BL
ZON
FSB
SSB
SSB
RSB
OFC
ZONE ORD N
LOT SZ
END.
SIDE
the permit is for one hundred ($100) o, less. I certify
issued, I shall not employ any person in any manner s
California.
If of 180 days `
INSURANCE: This section need not be
eperformance of the wo�k'for which t
Dme subject to the WoArs''Co mpensa
Date Applicant' X• } \ is311L,.yt ,`fS\i`'
M 4"
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forthwith comply with such p� visions or this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
O 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend. will be
made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or
demolition or dismantling'thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2. Art 2, Sec341, Tillell,
C.A.C.)
O As owner -builder, I will not employ anyone to do work which would require a permit from the Division of
Industrial Safety, as noted above, unless such person has a permit to do such work from that division.
O Division of Industrial Safety Permit No.
Date Applicant
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
Icertify that I have read this application and state that the above information is correct. I agree to comply with all
city and coonty'orbinances and state laws relating to building construction, and hereby authorize representatives
of this county to enter upon the abovementioned property for inspection purposes.
Signature of Applicant or Age` . Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENIRY: I certify I have read this application and state that
the information given is correct,�l'agree to comply�with all state laws and county ordinances relating to buidling
construl:tioli; a`d authorize a'represeotative of the City of N Ouinta Department of Building and Safety to enter
upon the property for which I have applied for this permit foilthe purpose of making inspections.
IV
Signature of%ppplicant or Agent Date/
Print Applicant/Agent Name ;
APPVPRMT 0 2 4 DAT
s' r
�Ile" f�7iJ
TOTAL
FEE
VALUATION/ f I•- S�V
Arrow Printing 250/1-83 White: Finance Canary: Assessor Pink' Applicant Tag: 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
�16
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.
❑
NO
ADDITIONAL INFORMATION
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath1311jL1
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
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