0761 (BLCK)�� ,; � '1-15' _,._ ..A X53, ���0
'' , '_ PERMITAPPLICATION
-,1 City of La Ouinta t 10
Department^oI Building and Safety"
JOB SITE ADORESS/SPACE
CITY/COMMUNITY/STATE/LIP
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: + •' r •' • • .•
!^
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if. :n
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'Compensation laws of ,
and eflecl.
California.
License Class Lic. Number
Date Applicant '
Date Contractor ^*
NOTICE TO APPLICANT: If; alter making this Certificate of.Exemption, you should become subject to the Workers-
., • ` • -"Compensation
OWNER -BUILDER DECLARATION. I hereby affirm that I am exempt from -the Contractor's License Law for thebe
`.
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 apermit. 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 to file a signed statement that he is licensedpursuanttothe provisions ofthe Contractor's License Law -
Cl I h6.reby certify that ho ex6avation five (5) or'more feet in 6pth into which a person is requirid to descend, 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• snd.that no building structure• scaffolding, falsework, or -
therefrom and the basis for the alleged exemption..Any violation of Sectiom7031.5 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, TilleB:'
subjects the applicant to a civil penally of not more'than,five hundred dollars ($500:):
C.A.C:)
O.I. as owner of the property, or my employees with wages as their sole compensation, will do the work, and the.. •
0 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 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
- ,
Division InduAtrial Safety Permit No.
through his own employees, provided that such improvements are not intended or offered for sale'. It, however, the •.
0 of
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.).
`'' CONSTRUCTION LENDING AGENCY:,I 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..•
oflthe 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
Contractor's License Law.).
Lender's Address
0.1 -am exempt under Sec. B. & 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
,
rof this county to enter upon the above-mentioned properly for inspection purposes.
' WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to sell -insure; or a
certificate of Workers' Compensation Insurance dor a certified copy thereof (Sect3800. Lab. C.):.'
Signature of Applicant or Agent - Date
. Policy No. Company R
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certity I have read this application and state that
O• Certified copy.is. hereby furnished. ->t,-"• •.+ _
the information given,is.correct. I agree to comply with all state laws and county ordinances relating to buidling
O Certified copy is filed with the City Building Inspection Department or City, i '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 Ihis'permit for the purpose of•making inspections-„ I
Date Applicant�T7%r1�7
!n �5/- �y
Signature of Applicant or Agent Date
APPLICANT NAME (L. F. MI)0 ^ 1 �' ��� ��E7 � '
` �d\Il..,i•. 1\
ADDRESS
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CITY/COMMUNITY/STATE/ZIP
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JOB SITE ADORESS/SPACE
CITY/COMMUNITY/STATE/LIP
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TRACT NAME
OWNER NAME (L. F. MI) `• ••
CONTRACTOR -FIRM NAME '
ADDRESS '
CITY/COMMUNITY/STATE/ZIP ,
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Citv of T&W
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ARC/ENG FIRM NAME '" •. - '
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE •
LICNC A
USE OF PERMIT
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END -
SIDE
Print Applicant/Agent Name
! ' VALUATION
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ti ,TOTAL
FEE
1 �' �t✓
! ' 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
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.
❑
NPON ADDITIONAL INFORMATION
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
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/1
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final