0620 (AR)PERMIT APPLICATION
_
. >w 1.11 tr.... ,. a...City of. La OufntaYn.,-
f� Department of Building and Safety
This permit becomes void if work.not commenced within 180 days from date of
issuance, OR, it work•.has:been.suspended or abandoned for a period of .180 days: •. . .
BON
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'CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSAT10N INSURANCE: This section need not be completed if `. .
LICENSED CONTRACTORS DECLARATION: I hereby affirm that Pam licensed under. provisions of :Chapter 9 +
the permit is -for one hundred ($100) It. less. l certify that in the performance otthe 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 force
Jssued, I.shall not employ.any person in any manner so as lo�become subject to the Workers'Compensation Laws,of.
and effect. r
California. ,
License Class. Lic. Number
Date Applicant K.
-Date . Contractor „ „'T.
NOTICE TO APPLICANT: If, after making this Certificati of.:xemption, you should become subject to the Workers'
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License.Law',lor the
rCompensation provisions of the Labor Code, you must forfnwith comply with such provisions or this permit shall
deemed revoked. -
-following reason (Sec. 7031.5. Business and Professions Code:.Any city or,county which requires a permit to
DI
.construct, alter; improve, demolish. or repair any structure. prior to its issuance, also requires the applicant for
DIVISION OF.INDUSTRIAL SAFETY PERMIT CERTIFICATIONI .. r
-such permittofile asigned statemenLthatheislicensed pursuant tothe provisionsoftheContractor'sLicenseLaw
0 1 hereby certify that no exdavation live (5) or more feet in Jepth intowhich a person is required to descend, will be
- .(Chapter 9(commencing;with section 7000) of Division 3 of the Business and Professions Code) or that he is exempt
- , made in connection with work•authorized.byihis permit, aid that no building structure, scaffolding; falsework, or • '
therefrom and the basis for the alleged ezemption.•Any violation of Section 7031.5 by any applicanttor a permit, r, r'r•
demolition or dismantling thereof, will be more than thirty -=ix (36) feet high. (Chap 3.2; Grp 2, An 2, Sec341,.Title8,
subjects the applicant to a civil penalty of not more than five hundred dollars (5500.): .rtV z C.A.C.)
. ❑ I. as owner of the properly, 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.oftered.for sale (Sec..7044, Business and, Professions Code: The Contractor's License
Industrial Safety, as noted above, unless such person ha : a permit to do such work from thatdivision:
Law does not apply to an owner, of property who builds, or improves thereon, and who does such work himself or
LICNC
•"through his own employees. provideddhat such improvements are not intended.or.offered for sale: If; however, the
0 Division of Industrial Safety Permit No....
building orimprovemnt.issoldwithinone year ofcompletion, the owner -builder will have the burden of proving that....
Date Applicant
he did not, build or, improve for the purpose of safe.). ..,j
CONSTRUCTION LENDING AGENCY: I hereby affirm that there rs a construction lending agency for the performance
• O I, as owner of the property, am exculsively contracting with licensed contractorsdo construct the project (Sec.
.. of the work for which this permit is issued (Sec. 3097, Ci... C.):. !: `.
7044. Business and Professions Code: The Contractor's License Law does not apply to an owner -of property who
Lender's Name' y
builds or improves- thereon, and who contracts for such projects with a contractor(s) licensed'pursuant to the
OFC-
Contractor's License Law.). ) .
Lender's Address
❑ 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 Js correct. I agree to comply with all
-• Date "' Owner
city and county ordinances and state laws relating to built--ing construction, and hereby authorize representatives
- -
of this county to enter upon the above-mentioned proper for inspection purposes.
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.). -
Signature of Applicant or Agent Date
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF EMTRY: 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 aJ state laws and county ordinances relating to buidling'-
and authorize a of the City .f La Ouinta Department of Building and Safety to enter,
❑ Certified copy is filed with the City Building Inspeclion'Departmenvor City Department.'
/4
,construction, representative
' 7 �` (-J ✓�yd�
Applicant
s upon the property'for which I have applied.for this per&-t.for the purpose of making inspections. .
Date
Signature of Applicant or Agent Date
Print Applicant/Agent Name t -
APPLICA81TZNfIJ1_E,(C^/vf1
ADDRES
CITY/COMMUNITY/STATE/ZIP
JOBSIAD
E ORESS/SPACE '
B Z5 c)
CITY/CGMMUNITY/STATE/ZIP -
BON
PAG
PRC
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FIND
SE
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TRACT.
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7
1.TRACT
MOD
Set
NAME
OWNER NAME (L. F. MI) -• ,
CONTRACTOR -FIRM NAME- '. .'..
.ADDRESS
CITY/COMMUNITY/STATE/ZIP
i
PHONE.J fV
��
ARC/ENG FIRM NAME
ADDRESS -
CITY/COMMUNITY/STATE/ZIP
PHONE N - •
LICNC
USE OF PERMIT ,
BL
ZON
FSB
SSB
SSB
RSB,
OFC-
-ZONE ORD •_
LOT SZ _
'END.-.�i s
, SIDE' ,
-APPUPRMT j L'j . -DATE C7Q
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. " wrty of q ..
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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.
❑
NO.
NO.
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
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