0640 (RPL)P '
PERMIT APPLICATION
d c • City of La Ouinta
I 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 fora jeriod of 160 days: .
ADDRESS'``/ -07vxv
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSAmION 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 3 of the Business and Professions Code, and my license is in full.torce
issued, I shall not employ any person in any manner soas0 become subject to the Workers'CompensationLaws of
and effect.
California.
License Class Lic. Number
Dale Applicant
Date Contractor
NOTICE TO APPLICANT: If, after making this Certificate o- Exemption„you should become subject to the Workers'
OWNER -BUILDER' DECLARATION: I hereby affirm that I am exempt from the Contractor's License for the
Compensation provisions of the Labor Code, you must to'thwith.complywith such provisions or this permit shall
'
-Law
' following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to
be deemed revoked.
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for -
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATIO'9:.
. - such permit to.file asigned statement that he is licensed pursuant to the provisions of the Contra.ctor.s Licensti-aw:o
1 hereby certify that no excavation five (5) or 6ore feet i I depthinto which a persoriis reqbired todescend;w ill be
(Chapter 9(commencing.with section 7000) of Division 3 of the Business and Professions Code) or that he is exempt
made in cohnectioh with work authorized by this permit.: nd that no building structure, scaffolding, falsework, or ..
therefrom and the basis for Ihe.alleged exemption. Any violation of Section 9031.5 by any applicant fora permit,
demolition of dismantling thereof, will be more than thirty; -six (36).feet high. (Chap 3.2, Grp Z Art 2. Sec 341, Title W,
subjects the applicant to a civil penalty of not more than five hundredtdollars ($500.):•
'CAC.)
D 1. as owner.of the property, or.my.employees with wages as their sole.compensation, will do the work, and the
0 A owner -builder; I will not employ anyone to do vArk' 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 his a'permit. to do'such work.from that division.
of improves thereon, and whoes such work himself or
Law does not apply to an owner of property who builds: o d
r : . . ,
through his own employees, provided that such improvements are not intended or offered for sale. If, however; the ---
D Division of Industrial Safety. PermityNo.
building or improvemnt is sold within one year of completion, the owner -builder will have the burden otprovingthat c...
Date - Applicant
he.did not build orimprovefor the purpose of sale.)..
I.;V-
, CONSTRUCTtON'L'ENDING AGENCY: I hereby affirm'that dere is a construction lending agency for the performance
O I, 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, ON. 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 Lam exempt under Sec. B. 8 P.C. (Attached Certificate). _
I'certify that I have read this.appl!cation 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 bui ding construction, and hereby authorize, representatives
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of this county to enter upon the above-mentioned proprrty for inspection purposes.
WORKERS' COMPENSATION DECLARATION: -1 hereby affirm that I have.a certificate of•consent to self -insure, ora .
-• END ,..
certificate of Workers' Compensalionlnsurance., or a certified copy thereof (Sec. 3800. Lab: C.).
Signature of Applicant or Agent ' ' Date
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF [NTRY: I certify'I have read this application and state that ' -
O: Certified copy is hereby furnished:
the information given is correct. I agree to comply with all state laws and county ordinances relating to.buidling
'representative the City La Ouinta Department Building Safety
D Certified copy Ifs tiled w th the,City Building Inspection�Depart/ment or City 'Department.
construction, and authorize a're of of of and to enter
P P 9 Y
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upon the property for which I have applied for -this permit for the purpose of making inspections. -
Date Applicant
Signature of Applicant or Agent Date
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ADDRESS'``/ -07vxv
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TOTAL
FEE •
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TRACT NAME
OWNER NAME (L. F. Ml) _- -
CONTRACTOR -FIRM NAME
ADDRESS -
CITY/COMMUNITY/STATE/ZIP .. -
PHONE •
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1�ys
ARC/ENG FIRM NAME ..
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE • -
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LICNC •
USE OF PERMIT
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RSB
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-• END ,..
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3 Print Applicant/Agent Name
APPL/PRMT • ■ g 4 3r als _�D_
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TOTAL
FEE •
. VALUATION �
BLDG. DEPT.
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.
❑
N
NO.
O.
ADDITIONAL INFORMATION
-
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/I
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final