0296 (BLCK)PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
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This permit becomes void it 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 WORKERS' COMPENSATION INSURANCE: This section need not be completed it
-LICENSED CONTRACTORS DECLARATION: I hereby affirm that I an licensed under. provisions of Chapter 9,
the permit is for one hundred ($100) o. less..) certify that in the performance of the work for which this permit is
(commencing with Section 7000) of Division 3 of the Business and Prolessions Code: and my license is in full force
issued. I shall not employ.any person in any manner so as to become subject to the Workers'CompensationLaws of
and effect.
California.
License Class Lic. Number
Date Applicant
Date' - ^ Contractor
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'_., .
OWNER -BUILDER DECLARATION: 'I hereby` ffirm that I am exempt" from 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 Prolessions.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 permit to file a signed statement that he is licensed pursuant to the provisions oftheContra ctor'slicenseLaw
.. .• 0 1 herebycertify that no excavation five (5) or more feet in depth into which a person is required to descend, will be
(Chapter 9(commencing with section 7000) of Division 3 of.the Business and Professions Code) orthat 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 the 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 8:M.
subjects the applicant to a civil penalty of not more than live hundred dollars ($500.): . -
C.A.C.)"
6•l1"s"owner
LICNC M
of the property, or my employees with wages as their sole compensation, will do the work, and the
O' As owner-buildef, I will not employ anyone to do work 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 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
through his own employees, provided that such improvements are not intended or offered for sale. If, however, the
t; Division of .Industrial Safety Permit No.
building or improvemni is sold within one year of completion. the owner -builder will have the burden of provingthat
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
.❑ 1, as owner of the property, am ezculsively contracting with licensed contractors to construct the project (Sec:
.. of the work for which this permit is issued (Sec. 3097; Civ. Q. '
7044, Business and Professions Cade: 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.). w
Lender's Address
'0 1 am exempt under Sec 0. B. B.P•.C, (Attached enificate).
I certify that I have read this application and state that the above information is correct. I agree to comply with all
� � t
. �P a` °
Date S Owner '
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
of this county to enter upoirthe above•mentioned property for inspection purposes.
WORK RS' COMPENSATION DECLARATION: Pereby affirm that 1 have a certificate of consent to self -insure, or a
a .
certificateof 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.ENTRY: 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
' O Certified copy is filed with the City Building Inspection Department or City Department. '
construction, and authorize a'representative of the City of La Ouinta Department of Building and Safety to enter
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
APP'IOy/y��.J/ rQ/ U}�/
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ADDRSSy
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6 ,
CITYY/ OMMU I >Y/SxATE/ZIP�
J08 SITE ADOj1ESS/S�P�W/ DA
CITYTY/COMMUNITY STATE Zl
BOK
PAG.
PRC
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RNG
SE
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TRACT
LOT
MOD
SB
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TRACT NAME
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 11
LICNC M
TOTAL
FEE
ARC/ENG FIRM NAME •.
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE 0
LICNC 0
USE OF PERMIT
81.
ZON
FSB
SSB
SSB
RSB
OFC
ZONE ORO 0
1
LOT SZ
END I
SIDE '
Print Applicant/Agent Name
APPL/PRMT ?q g0E1/�
7
1C
1f
07-
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y
City of La Qum a
TOTAL
FEE
J. C
BLDG. DEPT.,
VALUATION
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION I 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.
❑
OWN
ADDITIONAL INFORMATION
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SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath��
12A, Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
128 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 F final