0881 (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 fc^ a'period of 180 -days: '
PRC
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE:- This section need not be completed if -
LICENSED CONTRACTORS 'DECLARATION: I hereby affirm that J. am licensed under• provisions of Chapter 9
the permit is -for one hundred ($100) o, less.•I certify 0at-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 lull force '
" issued; I shall not employ any person in any mannersoas to become subject to the.Workers' CompensationL'aws of =
• and effect.
California. '
License Class • Lic. Number
Date Applicant
Contractor -
NOTICE TO APPLICANT: If, after making this CertificaL of Exemption. -you should become subject to the Workers' -
�, •-
OW ;.. N• -ER -BUILDER DEC"LARATION:• '- -
o .•'.
I hereby aflirm`ihat I am • ex.enlpttroin the CC o-'ntracttiir'sLicense Law for the
Compensation provisions of the Labor Code. you mus.forthwith comply with such provisions or this permit shall
'' en -
• • following reason (Sec. 7031.5. Business and Professions Code:. Any city or county which.requires a'permiLto
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 CERTIFICA"ION:. .
such permittofile asigned statement thatheis licensed,pursuan! to the provisions of the Contractor's LicenseLaw
❑-1 hereby certify that no excavation five (5) or more feei ih depth into which a person ig required to desdind, 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 6y this perrct; and that no.building structure, scaffolding, falsework: or -
therefrom and the basis for,the alleged exemption: Any.violation of Section.7031.5,by.any, applicant for a permit:-
demolition of dismantling thereof, Will be more than'th:rty-six,(36)•feet high. (Chap 3.2, Grp 2, Art 2, Sec341, Title 8;'.
' subjects the applicant to a civil penalty 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 - ;'
'. 'p As owner -builder, I'wifl'not employ anyone to do work which would require a permit from the Division of .
structure is not intended or offered forsale (Sec. 7044, Business and Piofessions.Code: The Contractor's License
. - Industrial Safety; as noted above, unless such persor 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- .-
O Division Safety Permit,No.
through his own employees: provided that such improvements are'not intended or offered for sale. If, however; the -
of.lndustrial
building or impiovemnt is sold within one year of completion, 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 tha: 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: '.
of the work for which this permit is issued (Sec: 309, 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 improvesthereon, and who contractsdor such projects: with a contractors) licensed pursuantto the
Contractor's License Law.).
Lender's Address
❑:I am exempt under Sec:' " ^ ^ B'8 P C..(Attached'Certificate).
`• z -Y. �y^
I certify that I have -read this application and state tha: the above information is correct. I agree to comply with all.
laws to luilding hereby authorize
�: 7,,i' ,.; l_ / >f ..
' :Date Owner\
.' city and county ordinances and state relating construction, and -representatives
- ..
'
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. CJ'. � t'-."-. _: ^.
.
Signature of Applicant orAgent Date
,Policy No. Company,
CERTIFICATE OF COMPLIANCE,AND AUTHORIZATION OF ENTRY. I certify I have read thisapplicatiohand statethat . '
O Certified•copyis hereby furnished.. .. .. •. ..,. ...
' -the information given is correct. I agree to comply witi all state laws and county ordiriances'relating to.buidling'. ql
' O Certifiea.eopy is:filed wiih the City Building Inspection Departmentw City' Department..
construction,and authorize a representative of the Gly of La Ouinta Department of Building and Safety to enter ..
upon the property.for•which I have applied for this p!rmit forthe'purpose of making inspections: :-
Date Applicant
'
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPLICANT NAME (L. F, MI)• -
Maria RM Pine
ADDRESS' - - •. .
52-555 Ramirez
CITY/COMMUNITY/STATE/ZIP
La Ouinta. CA 92253
.JOB SITE ADDRESS/SPACE - -. -
SAM
CITY/COMMUNITY/STATE/ZIP 4 : ��L•
La QA=ta. CA 92253
BOK-
PAG
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FIND.
SE
S.
TRACT -
LOT
-
MOD
SB
TRACT NAME
OWNER NAME (L. F. MI).. �•��� - -
►�ME
CONTRACTOR -FIRM NAME ,, • ., ,.
ADDRESS ••
CITY/COMMUNITY/STATE/ZIP - - - • -
I f
1
PHONE a'
LICNC 8
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP - -
PHONE A •
' LICNG M
. .
USE. OF PERMIT - ' '
Basketweave Fence
St.
ZON
FSB
•SSB <
SSB..
RSBOF
C
' ZONE ORD n
- LOT SZ; �•
` .: •! -
' EN
• '•
D '.SIDE.
VALUATION;
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
NO. ADDITIONAL INFORMATION.
% %�jy
// p
-
`
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)
14Final
PLUMBING APPROVALS
15 Ground Plumb
16 Water Piping
0 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