0325 (PAT)° 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 for a period of 180 days. .
LICENSED .CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions 'of Chapter 9'
(commencing with Section 7000) of -Division 3 of the Business and Professions Code, and my license is in full force
and effect.
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
the permit is -for one hundred ($100) o, less. I certify that in the performance of the work for which this permit is
• issued, I shall not employ any person i n any manner so as to become subject to the Workers' Compensation Laws of
California.
License Class - Lic.NNu/mber
Date Applicant
_
' Date v �/ :w • • Contractor / . `
NOTICE TO APPLICANT:. It, after making this Certificate of Exemption; you should become subject4o the Workers'.,, .
OWNER -BUILDER DECLARATION' I hereby affirm that I am exempt from the Contractor's License Lew 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
PAC
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 fileasignedstatementthatheislicensedpursuanttotheprovisionsoftheContractor,'sLicenseL•aw
"• 01 hereby certify that no excavation five (5) oir more feet in depth into which a peison is requiied to descend, will be
(Chapter 9 (commencing with section 7000),of Division 3 of the Business and Professions Code) or thathe is exempt
made in connection with'work authorized by this permit, and that no building structure, scaffolding, fatsework, or '
• therefrom and the basis for the alleged exemption.. Any violation of Section 7031.5 by any applicant for a•permit , ,;
- • demolition or dismantling thereoi,"vvill be more than thirty-six (36) feethigh. (Chap 3.2, Grp 2,'Art 2, Sec341, Title8,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
C.A.C.)°
0 I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the
0 Al owner -builder, I will ndt employ anyone to do work which -would require a permit from the Division of
structure is not intended or offered for sale (Sec. 709, Business and. Professions Code: The Contractor's License '
Industrial Safety is noted above, unless such person has'a permit to do such work from that division.
Law does not apply to an owner of property builds, or improves thereon• and who does such work himself or
CONTRACTOR -FIRM E '.
<�n es
through his own employees, provided that such improvements are not intended or offered for sale. It. however, the- :
0 Division of. Industrial Safety Permit No..
' building or improvemnt 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.).
0 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
buil(fs or improves thereon, and who contracts for such'projects with a contractor(s) licensed pursuant to the '
Contractor's License Law.).
0 I am exempt under Sec. B. 8 P.C.'(Attached Certificate).
Date ` Owner
' 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. C.).
Policy No. Company
0
�Certified copy is hereby furnished..
CT Certified copy is filed with the City Building lnsti tion/,peparl pe f t, I Department.
DateIOIII�1 J Applicant �^r ( C
APPLICANT
ADDRESS '
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CITY/COMMUNITY/STATE/ZIP
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TRACT NAME
OWNE��RyNAME (L. F. Mg -
CONTRACTOR -FIRM E '.
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•CITY/COMMUNITYY//STATE/ZIP
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PHONE IILICNC
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ARC/ENG FIRM NAME -
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE 0
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USE OF PERMIT '
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SSB
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END. '
SIDE
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. 3097, Civ. C'.)'.
Lender's Name
Lender's Address
I certify that I have read this application and state that the above information is correct.I agree to comply with all
city and county ordinances and state laws relating to building 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 with all state laws and county ordinances relating to buidling
construction, and authorize, "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 Date
Print Applicant/Agent Name
APPL/PRMT 0.1 21 ri Id
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Alllldl'Ap, drewi74'
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TOTAL
FEE
VALUATION
r.
S
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back*
33 "
Ventilation System
2
Ftgs & Frms
/� �3
j
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
®
Z-
39
Appl. Clearance
T
Framing_
/D
40
Fire Damper
8
Vents
41
Smoke Detection Device. ,
%
Garage Fire Wall
42
Commercial Hood
10
Fireplace P.Li ❑
43
Final
10A
Fireplace T.O.
❑
NOON
ADDITIONAL INFORMATION
✓�% ..1 -2
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
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