0635 (RPL)APPUPRMT - „n:S3%A�TE g.11. �•�� ,
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TOTAL �•�"
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PERMIT APPLICATION
City
of La Ouinta
` Department of Building and Safety
�-"•vim=_c..1 ..
PRC
This permit becomes void if work not -commenced within. 180 days from date of issuance, OR, if work has been suspended or abandoned for period,ot•180 days:
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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 Chapter 9
,, the permit is'for ane hundred ($100)o, less.) certify. thefin the.performance of the workior which this permit'is •
(commencing with Section 7000) of Division 3 of the Business and Professions Code; and my license is in full force. '
issued, l shall not -employ any person in anymannerso a; to become subject to the Workers' Compensation Laws of
and elfect.
"California. - '
License Class' Lic. Number
Date Applicant
s-•
Date e • -Contractor'
^
NOTICE TO APPLICANT:If, after,making this Ceitificate:)f Exemption; you should become subject to the Workers-,;.,
' b:• ' t . - - ,
OWNER -BUILDER DECLARATIONS Iherebyalfirm that•I am' exempt from the Contracto'r's License Law•for the -•'
Compensation provisions. of the. Labor Code, you must torthwith comply with such provisions or this permit shall ^ 'a
- •
' '
following reason (Sec. 7031.5. Business and Professions Code: Any city, or. county which requires a.permit to
^ be deemed'ievaked. , , ;
^ construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
•.. ' .DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law,..
„p'Iherebycertify thatnoexcavationfive(5)ormore fee- indepth into whichapersonisrequired todescend,will be '
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) or that heis exempt '
, 'made in connection -with work authorized•by this permit' and that no building structure, scaffolding, falsework, or • :
. i therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit;.'
demolition or dismantling (hereof, will be more than thiry-six (36) feet high.. (Chap 3.2;Grp 2 -Art 2, Sec 341, Title8; '
subjects the applicant to a civil penalty of not more than five hundred -dollars (5500.):
C.A.C:) " ` 1,' L f ^'
0 •l, as.own er of the property, or my employees with wages as their -sole compensation; will do the work, and the a
- ! ' 0 As. owner�builder,'I will not employ anyone to do a/ork 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 ias 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 suchwork himself or
u-'
through is own employees: provided that such improvements are not intended or -offered for sale. If, however, the
0 Division of..lndustrial Safety Permit No.
-.building orimprovemntissold within one year ofcompletion, the owner -builder will have the burden of proving that
Date ' Applicant—
he did not build or.improve for the purpose of, sale). p
CONSTRUCTION LENDING AGENCY: I hereby affirm that=.hese is a construction lending agency for the performance '
v 0 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:Civ..C:). •
7044, Business and'Professions Code: -The Contractor's License Law does not apply to an owner of property who
L'ender'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
' 0 1 am exemptunder Sec. ' • - ` . B. 8 P.C. (Attached Certificate)—, •:
. ' . I certify that I have.read:this application and state that he'above information is correct. I agree to•comply with all .
Date - Owner
city and county ordinances and state laws relating to be ilding construction, and hereby authorize representatives
'
of this county to enter upon the above-mentioned property for inspection purposes.
' WORKERS' COMPENSATION DECLARATION: I herebyeffirm that I have a'certificate of consent to self -insure; or a!'
-certificate:ot Workers' Compensation'Insurance ; or a certified copy thereof '(Sec. 3800. Lab. C.):
Signature of Applicant or Agent Date
..Policy No. Company
CERTIFICATE -AF COMPLIANCE AND AUTHORIZATION OPENTRY: I certify I have read this application and state that
• t ❑Certified copy. is hereby furnished.
^Department.- !
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 City of La Ouinta Department,of Building and Safety to enter,
0 Certified'copy is filed) the City Building Inspection or City / Department.
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GrJ e �1 ! 1 !
''Applicant�i
,
upon the property for which I have applied for this permit for the purpose of making inspections
Date 1 /.0 -? 7 �7.✓
.. ._. ..
'
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPUPRMT - „n:S3%A�TE g.11. �•�� ,
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CI-.T,V/•COM�UNITY/gxpTE/ZV� / ; (,+ //�,/y
'SJOB SITE ADSiIi /AC►E J•;
ITY/C UNITY//STATE/ZIP -
CITY/607
21 .41'
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FIND
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TRACT NAME -
OWNER NAME (L. F. MI) .. • ,.
CONTRACTOWFIRM NAME - -
ADDRESS
CITY/COMMUNITY/STATE/ZIP ' . • .
1
y—y-
/7/vo .S
ARC/ENG FIRM NAME • • '• '-
ADDRESS
CITY/COMMUNITY/STATE/ZIP - - -
PHONE • -
LICNC •
-
USE OF PERMIT
BL
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''FSB
SSB.
SSB
RSB -
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- . ZONE ORD a,
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APPUPRMT - „n:S3%A�TE g.11. �•�� ,
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TOTAL �•�"
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NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION DATE NSP.ECTOR
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'N
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
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