0298 (BLCK)PERMIT APPLICATION
' City of La Ouinta
Department of Building
and Safety
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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.
BOK
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: 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. [shall not employ any person in any manner so as to become subject tothe Workers'CompensationLaws of
I and effect.
Californ�ia////
/ -
License Class Lic. Number
Date ; Applicant>J
Date Contractor
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'.
OWNER -BUILDER DECLARATION: I hereby affirm that I am 'exempt from the Contractor's License Law for the..
Compensation,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
'
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 statementthat heislicensed pursuant totheprovisionsofthe Contra ctor'sLicense Law
O`Ihereby certify that noexcavation five (5)ormore feet indepth into which aperson isrequired todescend,willbe
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and ProfessionsLode) or that hells exempt
made in connection with work authorized by this permit, 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 or dismantling thereof• will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec 341, Title 8.
subjects the applicant to a civil penalty of not more than five hundred dollars (8500.):
C.A:G:)''t• .
• O I. as owner of the property, or my employees with wages as their sole compensation, will do the work, and the
O 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. -70M, Business and Professions Code: The Contractors License .
Industrial Safety, as noted above, unless such persomhas 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
r
through his own employees, provided that such improvements are not intended or offered for sale. If, however; the
O Division of Industrial Safety Permit No.
1building or improverrint is sold within one year of completion, the owner -builder will have the burden of proving that
Date Applicant
he did not build er, improve for the purpose of sale.). 1,, '
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
O 1, 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, 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
O 1 am exempt under Sec. A. 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 .
. SIDE
of this county to enter upon the above=mentioned property for inspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that 1 have a certificate of consent to self -insure, or a, -
certificate of Workers' Com ensation Insurance or a certified cop thereof 'Sec *3800 Lab C ) >
. D Y
Policy No. Company
O Certified copy is hereby furnished.. ,
C Certified copy is filed with the City Building Inspection Department or City Department.
Date Applicant
APPLICANT NAML. MI)
ADDRESS
CITY/COMMUNITY/STATE/ZIP
JOB SJTE,A•DORESS/SP LCE • ` ��w��
CITY//COMMUNITY/STATE/ZIP
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ARC/ENG FIRM NAME -
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1.END
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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 property for which I have applied for this permit for the purpose of making inspections.
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPUPRMT fl7,98
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TOTAL
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BLDG. DEPT. VALUATION
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NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION DATE INSPECTOFe
BUILDING.APPROVALS.
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms•
34
Plenums &.Ducts- '
2A
Slab Grade
3'5
Eurnace.Compart.- "
3
Steel
36 '
Inlets &Outlets -
4
Grout,Blocks
37.,
Combustion -Air ..
5
Bond:Baeams
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' ADDITIONAL INFORMATION
P.2 �71 '
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
PSL P/L
STREET NAME
26 Power Pole
27 Conduit
28 Service. Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures.
31 Service
32 Final