0205 (RPL)PERMIT APPLICATION
City of La Otjinta
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
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENS ATIONINSURANCE: 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 ($100) o, 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 full force issued. I shall not employ any person in anymannerso as to become subject tothe Workers'CompensationLaws of
and effect. California.
License Class
Date
Contractor
Lic. Number
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 to
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) or 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 ($500.):
❑ I, as owner of 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 pioperty 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.).
❑ 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.).
❑ 1 am exempt under Sec
Owner
B. 8 P.C. (Attached Certificate).
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. Q.
Policy No. Company
• Certified copy is hereby furnished.
❑ Certified copy is filed with the City Building Inspection Department or City Department.
Date Applicant
APPLICANT NAMr7(L. F.,MII))P A �y
ADDRESS r
CITY/COMMUNITY/STATE/ZIP
JOB SITE ADDRESS/SPACE
CITY/COMMUNITY/STATE/ZIP M�UNNITTYY//STATE/ZIP
BOK
PAG
PRC
C
TWN
PING
SE
S
TRACT
LOT
MOD
SB
TRACT NAME
OWNER NAME (L. F. MI)
CONT ACtTOR�-FyIRM �NnAME
1 I..Y�/. M
ADDRESS
CITY/COMMUNITY/STA TE/ZIP
`PHONE N
LICNC N
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE*
LICNC N
USE OF PERMIT
BL
ZON
FSB
SSB
SSB
RSB
OFC
ZONE ORD N
LOT SZ
END
SIDE -
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificateot Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must orthwith comply with such provisions or this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICAT ON:
❑ 1 hereby certify that no excavation five (5) or morefee! 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 thir.y-six (36) feet high. (Chap 3.2. Grp 2, Art 2, Sec341, Title8,
C.A.C.)
❑ As owner -builder, I will not employ anyone to do vork which would require a permit from the Division of
Industrial Safety, as noted above, unless such person :las 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. 3D97,Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that he above information is correct. I agree to comply with all
city and county ordinances and state laws relating to b rilding construction, and hereby authorize representatives
of this county to enter upon the above-mentioned property for inspection purposes.
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 wit@ all state laws and county ordinances relating to buidling
construction, and authorize a'representative of the. Ci y of La Ouinta Department of Building and Safety to enter
upon the property for which I have applied for this pq-mit for the purpose of making inspections.
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMT �f 0 DATE
e-
11.,9
11/9 t.2.ar''"a
ECEIVED
AUG 3 J93
Clby Of La Quint
V
TOTAL
FEE
VALUATION
Arrow Printing 250/1-83 White: Finance Canary: Assessor Pink: Applicant Tag: Bldg. Dept. /a ,�.
./
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.
❑
OP'N ADDITIONAL INFORMATION
NO.
/� 31P�
r/ �2 / �j�
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