0305 (GRD)PERMIT APPLICATION
City of La Duinta
Department of Building and Safety
5Z %4r�
This permit becomes void if work not commenced within'180'days from date of issuance. OR, if work has been suspended or abandoned fora period of 160 days.
'
CERTIFICATE OF EXEMPTION FROM WORKERS COMPEN..ATION INSURANC . Is section nee not a comp e e I
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 any manner so a to become subject to the Workers' Compensation Laws o1
and effect. California.
License Class Lic. Number Date Applicant
DateContractor
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 thathe 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.):
'O 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 property 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 i mprovemnt 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.).
O 1, as owner of• theproperty, 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.).
O 1 am exempt under Sec. B. & 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 Noe Company
O C�ed copy is hereby furnished.
O Certified copy is filed with the'City Building Inspection Department or City Department.
Date Applicant
APPLICANT SME (L, FF", M11rm /A Me // J 4 '
ADDRESS��
CITY�/COMMUNITY//STATE//ZI,Pl
JOB SITE ADO�ESS/S�1/ s ,
CITY�Y//COOMMMUNIT:Y/STTAATE/ZIP-
,e d, aim �, 9� 2 S•-3
BOK PAG ,�� PRC_ y
tKJC/Ji,//LOT��
C
TWIN
PING
SE
S
TMC7�;
CJty of La Quinta
TOTAL •
FEE
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/ /
MOD
Set
TRACT NAME '
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 1
LI NC
ARC/ENG FIRM NAME -
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE,
LICNC 0
-
USE OF PERMIT
BL
ZON
FSB
SSB
SSB
RSB
OFC
ZONE ORD
I
LOT SZ
END
SIDE
.. NU I IUt I U APPLILAN I: it, aner maKing mis ueruncaie:ol txempuon, you snonm oecome suolecl to me womers
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:
O I hereby certify that no excavation five (5) or more fee. in depth into which a person is required to descend, will be
made in connection with work authorized by this permin, and that no building structure, scaffolding, falsework, or
demolition or dismantling thereof, will be more than thiry-six (36) feet high. (Chap 3.2, Grp Z Art 2, Sec341, Title8.
C.A.C.)
O As owner -builder, I will not -employ anyone fn do work whichwould- require a permit from the Division of
Industrial Safely; as noted above, unless such'person -ias 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 here is a construction lending agencyfor 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 fie 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
CERTIFICATEOF 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 CiLr 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
14
APPL/PRMT
.�0
/117114 Ciie,ci� /S, 0
}0
w ;
CJty of La Quinta
TOTAL •
FEE
�%!?
/ /
BLDG. DEPT.
VALUATION J�
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
f=ireplace T.O.
❑
0'N
NO.
ADDITIONAL INFORMATION
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath`%/?%Z/a��
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
29B Bonding
30 Fixtures
31 Service
32 Final