0113 (PLBG)LICENSED CONTRACTORS DECLARATI
(commencing with Section 7000) of Oiv1
and effect.
License Class Lic. Number
Dale Contractor
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 Prolessions 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 that he 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 live hundred dollars (S50G):
❑ 1, as owner a1 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 [hereon, 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 improvemnl is sold within one year of completion, theowner-builder will have the burden of proving that
he did not build or improve for the purpose of sale,).
❑ 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
builds or improves [hereon, and who contracts for such projects with a contractor(s) licensed pursuant to the
Contractor's License Law-).
❑ 1 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 [hereof (Sec. 3800. Lab. C.).
Policy He. Company
❑ Certified copy is hereby furnished,
❑ Certified copy is filed with the -City Building Inspection Department or City Department
Date — Applicant
APPLICANT NAME (L. F. MI)
ADDRESS
CITY/COMMUNITY/STATE/ZIP
JOB SITE ADDRESS/SPACE
CITY/COMMUNITY/STATE/Z I P
BOK
PAG
PRC C
TWN
RING
SE
S
TRACT
LOT
MOD
SB
TRACT NAME
OWNER NAME (L. F, MI)
CONTRACTOR -FIRM NAME _
ADDRESS
CITY/COMMUNITY/STATE/ZIP
f
PHONE X
LICNC X
4f -
ARClENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE X
LICNC X
USE OF PERMIT
BL
ZON
FSB
SSB
SSB
RSB
OFC
ZONE ORD X
LOT S2J.
END
SIDE
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.
CERTIFICATE OF EXEMPTION FROM WORXERS' COMPENSATION INSURANCE- Thlssei:llonneodnot hetompletedif
ON: I hereby affirm that I am licensed under provisions of Chapter 9 the permlLls for one hundred f51M a, less. I cerilly that m Ifla parformance of the work for which this permit is
sion 3 of the Business and Professions Code, and my license is in lull force issued.lshall not employany person In any mannersoastobecomo subject to the Workers'CompensationLaws of
Calilomia
Date Applicant
NOTICE TGAPPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forthwith comply with such provisions or [his permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five (5) or more feel in depth into whlsh a person is required to descend, will be
made in connection with work authorized by [his permit, and that no hullding slrucIure.scalfolding, falsework,or
demolition or dismantling thereof, will be more than lhitly-six (36) feel tllgh. jChap 32 Grp 2, Art 2, Sec34L TitleB,
C-A,C-)
❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of
Industrial Safety, as noted above, unless such person has a permit to do such work from that division.
El Division of Industrial Safety Permit No -
Date Applicant
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 stale that theabove 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=mentloned 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 a representative of the Cil} of La Ouinta Department of Building and Safely 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
APPL/PRMT r DATE
VON 121.Y)
i
TOTAL
FEE
Arrow Printing 250/1-83 White: Finance Canary: Assessor Pink: Applicant Tag: Bldg. Dept. VALUATION
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
1 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. ❑
NP'N ADDITIONAL INFORMATION
.2'j�'f
I
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
PIL P�1
STREET NAME
26
Power Pole
27
Conduit
28
Service Entrance
29
Wiring
29A
Grounding Wire
29B
Bonding
30
Fixtures
31
Service
32
Final