0663 (RER)APPUCANTrNA �E (L=7F, MI)
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CITY/COM MUNIJ�V%7 ST ( / I to _
'IF
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PERMIT
APPLICATION
City of La Ouinta
' Department of Building and Safety
This permit becomes void it work not commenced within 180 days from date
of issuance. OR: if work has been suspended or abandoned fora period of 180 days.
:.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 Chaptei 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 Sol the Business and Professions 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
California: 6A
• License Class Lic. Number
Date Applicant
• Date -' Contractor • -
•. NOTICE TO APPLICANT: If, after making this_Cerdificate of Exemption, you should become subject to the Workers:
OWNER -BUILDER DECLARATION: I hereby affirm't;at 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
- .• -
following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
be deemed revoked. •- " • .i _ '
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant forDIVISION
OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
such permit to file a signed statement that he is licensed pursuant to the provisions ofthe Contra clot's License Law
0 1 6retiy*tiertify that no exbavatiorifive (5) or more feet in depth into which a person is required to descend, will be' '
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Cade) or that he 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 thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, An 2, Sec341, Titlell,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
C.A.CJ,
,O 1. as owner of the property. -.or my employees with wages as their sole compensation, will do the work, and the
-0 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
OFFS
through his own employees. provided that such improvementsare not intended or offered for sale..lf: however, the
O 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.)..CONSTRUCTION
LENDING AGENCY: I hereby affirm that the is a construction lending agency for the performance .;
-.0 I, as owner of the property, am exculsivelylcontracting 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,ol property who
•
Lender's.Name
builds or improves thereon, and who contracts lot such projects with a contractor(s) licensed pursuant to the
-,;.END
Contractor's License Law.):
Lender's Address
0 1 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 '
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. C:)::
Signature of Applicant or Agent • Date
ti Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: Icertifyd have read this application and state that
0 Certified copy is hereby furnished.
the information given is correct. l agree to comply with all state laws and county ordinances relating to buidling
^<, '0 Certilied/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
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upon the property for which I have applied forthispermit for the purpose of making inspections. y
Date Applicant
^
Signature of Applicant or Agent Date
APPUCANTrNA �E (L=7F, MI)
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CITY/COM MUNIJ�V%7 ST ( / I to _
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USE OF PERMIT
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SIDE
Print Applicant/Agent Name
APPUPAMT )ATE
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APR 101984
city of La Quinta'
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TOTAL`
FEE
L. . VALUATION '(YC/ II 610.• • ` .BLDG., DEPT. ;'
0
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'NO.
ADDITIONAL INFORMATION
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
73 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 PiI
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final