0330 (RR)+ 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.
• 3 ;.
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 .
thepermit 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.force .
issued, I shall not employ:any person in any manner so asto become subject to the Workers'Compensation Laws of -
and effect.
California.
License Class Lic. Number
Date Applicant
• • Date °• Contractor
NOTICE TO APPLICANT: IL after making this Certificate,of Exemption, you should become subject'to the Workers' ,
OWNER -BUILDER DECLARATION: I hereby affirm that I am exemptirom 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.
construct, alter, improve: demolish, or repair any structure; prior to its issuance, also requires the applicant for •. •
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
such.permittofile asigned statement thatheislicensed pursuanttotheprovisionsofthe Contractor's License Law
0 1 hereby certify that no 6xcavatio6 five (5) or more feet in depth into which a person is required td descend, will be' r
,(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 by this permit, and that no building structure, scaffolding, falsework, or -
therefrom and the basis for.Ihe 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, Art 2, Sec341, Title B; '
subjects the applicant to a civil penalty of not more than lWie hundred dollars ($500.):
C.A.C.)
. O I, as owner.of the property, or my employees with wages as their sole compensation, will do the work, and the
O As ownerabuilder, I will not employ anyone to do work which would require a•permit.from the Division of '
structure is, not intended oroffered 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
USE OF PERMIT _
through his own employees, provided that such improvements are not intended or offered for sale. ll, however, the
O Division of Industrial Safety Permit No. _
•
building or improvemni 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 there is a construction lending ,agency for the performance '
O I, as owner of the properly, am exculsively contracting with licensed.contraclors to construct the project (Sec. +
.'•, of the work for which this permit is issued (Sec. 3097, Civ. C.).. �, - •• - - ' S
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.
• ZONE ORD ..
Contractor's License Law.). _ . . .
Lender's Address
• • O 1 am exempt under Sec.' Br8 P.C. (Attached Certificate):
I certify that I have read thisapplication and state that the above information is correct. ) 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. C
• 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. Q.
Signature of Applicant or Agent" Date "
. Policy No. ,Company- - -
CERTIFICATE OF COMPLIANCE AND'AUTHORIZATION OF ENTRY: I certify I have read this application and state that C.
O Certified copy is hereby furnished. j- s
the information given is -correct. I agree to comply with all state laws and county ordinances relating to buidling
❑ Certified copy is filed with the City Building Inspection'Department or City Deparlment. • •.
', construction; and authorize a'representative o1 the City of La Ouinta Department of Building and Safety to.enter ,
-1 11%..
upon the property for which I have applied for this permit for the purpose of making inspections. -
Date Applicant
,APPLICANT NAME (L, F. MI)-- •) • •'-•7�'
6)2C>rs A c ] (c, til % F <a P . _2 o C.
ADDRESS r/ • ' '
10
T/Y/COMM/U�NITY/STATE/ZIP �j �•j '- / //
CII\,/
JOB SITE ADDRESS/SPACE
CITY/COMMUNITY/STATE/ZIP ,
r�
BOK '
PAG PRC.
'C
- ..
TV N
FIND.
SE
S
TRACT
LOT
MOD
SB
TRACT NAME
OWNER NAME (L, F. MI)
CONTRACTOR -FIRM NAME - -
�IA,caa� .
ADDRESS
CITY/COMMUNITY/STATE/ZIP .,
PHONE . -
L CNC .-
ARC/ENG FIRM NAME ,•U..
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE.
LICNC
81983
USE OF PERMIT _
BL
Quini,
20N
TOTAL
FEE
FSB
SSB
SSB;
RSB.
• ZONE ORD ..
- LOT SZ .
END
SIDE
Print Applicant/Agent Name
APPL/PRMT
o( -J J A R E C _
-
U,
('i M 1 17k�.
46.60
NEiLT v
UO
81983
IU
ON
City Of La
I
Quini,
'
TOTAL
FEE
901
BLDG. DEPT.
•• / D
VALUATION -Idoo,o .`
NO.
OPERATION DATE
INSPECTOR
NO. OPERATION I DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVAL'S
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 ADDITIONAL INFOR ON .
NOTI
/
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A{{l
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