0597 (BLCK)PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
33--/ 3 2
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 • i� �7 �.
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
LICENSED CONTRACTORS DECCARA'TION: I hereby affirm thatol 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 Secllon'7000) of Division 3 of the Busipess and& fissions 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 effect. �%r/ ! j{/lw
California.
' NilL-icense Class iNv Lic.'Number
Date Applicant
Date Contractor
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
/Compensation
OWNER-BUILDEfi DECLARATION: I.heteby affirm that I am exempt from the Contractor's License Law.for the
provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall,:
be deemed revoked.
following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to
40
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-tofile a'signedstatement that heislicensed,pursuant tothe provisions ofthe Contractor's License Law
" 0 1 hereby certify that do excavation five (5) or more feet in depth into which a person is required to descend, will be
• (Chapter 9(commencfng 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, and that no building structure, scaffolding, falsework, or
r.- therefrom and the 'b ' asis for the -alleged exemption. Any violation of Section 7031.5 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, Title B.
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
C.A'C.)• vk.
0 I, as owner of the property, or my employees with wages as their sole compensation, will do the work', and the, '
(b 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. -
d' ,
through his own employees, provided that such improvements are not intended or offered for sale. If, however,9he
0 Division of Industrial Safety Permit No.
building or improvemni is sold within one year of completion, the owner -builder will have the burden of provingthat
Dale ..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
0 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. 3097, CW Q.
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
SSB
Contractor's License Law.).
Lender's Address
O I am exempt under Sec. B. 8 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
LOT SZ
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, or a
END
'• certificate of Workers' Compensation Insurance , or'a certified copy thereof (Sec. 3800. Lab. C.).
-
Signature of Applicant or Agent Date
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
0 Certified copy is hereby furnished. ,.. _ .a ..
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling -w
0 Certified copy is filed with the City Building Inspection Department or City 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 this permit for the purpose of making inspections.
Date Applicant
APP.1 N NAME (L. F, AA%•,<,Q �''ON sT • .
'ADDRESS AJ,�,� ! 0 5
CI OMM`_UNI,V �STATE/ZIS
JOB.SITE�-,A-DR_EvSSIS� /ACE ,[� / y/�'¢ ,✓� q ,1 . V
/ V
CIT�Y/COMM UN/1 /ST�ATTE ZIP/
c
BOK
'PAG
PRC
C
'
TWN
RNG
SE
S
TRACT
LOT
40
MOD
SB
TRACT NAME
CONTRACTOR -FIRM NAME '
AODRESS"X .
CITY/COMMUNITY/STATE/ZIP
PND_1 _4TT/
3�0°/5��7
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 1
LICNC
TOTAL '.
FEE FEE •
USE OF PERMIT
SL
ZONFSB
SSB
SSB
RSB
ZONE ORD'I
LOT SZ
END
SIDE.
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPUPRMT
Lu Wq44.
1�,,CA,l / 7'
7-0
t1�5.
_rO7 A
40
�jT s�a
TOTAL '.
FEE FEE •
7 -
VALUATION 35J• ��
BLDG. DEP-
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,2
/$ % . /'f
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 R
Value
7A Walls (Batts)
126 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
296 Bonging
30 Fixtures
31 Service
32 Final