0360 (BLCK)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. •
LICENSED CONTRACTORS DECLARATION: I hereby.affirm that -1 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. G„ 7
License Class Lic. Number /
Date����✓�A Contractor.
OWNER -BUILDER DECLARATION: I her affirm that I am exempt from.the Contractor's License. Law, for the ."
following reason (Sec. 7031.5. Business and Professions Code: Any cityor county which requires.a permit to
construct, alter, improve, demolish, or repair any, structure, prior to its issuance, also requires the applicant for.
such permit to file asig ped 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) orlhat 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 ($500.):
Q; 1. 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. It, 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.). .
0 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.). _.
-0 1 am exempt under Sec. . 8. 8 P.C. (Attached Certificate). _
Date ' Owner
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to sell -insure, or a'
certificate of Workers' Compensation Insurance , or a certified copy thereof -(Sec. 3800. Lab. C.).
Policy No. Company
0 Certified copy is hereby furnished.
O Certified copy is filed with the City Building Inspection Dripartmentor City
Date Applicant
Department.
APPLICANT NAME (L. F. MI) ! c
J
0S
ADDRESS ••
f % /0 A V
CITY/COMMUNITY/STATFJZIP ,
JOB SITE ADDRESSISPACE -
CITY/COMMUNITY/STATE/ZIP
BOK
PAG
PRC
C
TWN
RNG
SE
S
TRACT
LOT
MOD
SIB
TRACT NAME •' ,
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME.
ADDRESS��.'O
CITY/COMMUNITY/STATE/ZIP
•/
PHONE �-�)C
LICNC 11
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE
LICNC n
USE OF PERMIT
BL
ZON
FSB
SSB
SSB
RSB
OFC
ZONE ORD 1.
LOT SZ
END
SIDE
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if -
the permit is for one hundred ($100) o, less. I certify that in the performance of the work for which this permit is -
issued. I.shall.not employ any person in any manner so as to become subject to the Workers' Compensation Laws of .
California.
Date Applicant
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 provisions or this permit shall
be deemed revoked.
DIVISION OF. INDUSTRIAL SAFETY PERMIT CERTIFICATION:
0 I 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, lalsework, or
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec 341, Title 8,
C.A.C.)
0 As owner -builder, I will notemploy anyone to do work which would reggire a permit from the.Divisionof
Industrial'Safety, as noted above, unless such person has a permit -to do such work from that division.
❑ Division of Industria(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
I certify that I have read this application and state that the above information is correct. I agree to comply with all
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. a
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 propertyforwhich I have applied for this permit for the purpose of making inspections.
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPL/PRMT 9 R l _DATE
IyT�
/7"/n4
TOTAL
FEE
` Q
VALUATION ;7—
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
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
f=ireplace T.O.
EJ
NO. ADDITIONAL INFORMATION
/
L/� - I ala t�/Y,/
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
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