0409 (AR)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: it work has been suspended or abandoned for a period of 180 days.
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 30t the Business and Professions Code, and my license is.in full force
and effect. /, ' '
License Class —/ � C 'Lic. Number Dy
Date In^ Coot ractor
OWNER -BUILDER DECLARATION: �"I hereby affirm 'tbal am exempt from the Contractor's License Law for the
following reason (Sec. 7031.5. Business and Professions. Code: Any city or county which requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law
(Chapter 9(commencing with section 7000) of Division 3 of the Business and Professions Code) or that he isexempt
-therefrom and the basis for the alleged exemption. Any violation of Section7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
❑ I. as owner ot.the property, or my employees with wages as their sole compensation, will do the work, and the
structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License
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: Ii, however, the
building or improvemnt is sold within one year of completion, th6 owner -builder will have the burden of proving that
he did not build or improve for the purpose of sale.).
O I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec.
7044. Business and Professions Codec The Contractor's License Law does not apply to an owner of property who
builds or improves' thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the
Contractor's License Law.).
❑ I am exempt under Se/c. .-B. & P.C. (Attached Certificate). ,
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate'of consent to'selMnsure, or a -
certificate of Workers' Compensation Insurance, or -a certified copy thereof (Sec.. 3800, Lab. C.):.:
Policy No. Company
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the City Building inspection Department or City Department.
Date Applicant
APPLICANT NAME (L. F. MI; J 6,44 CaA1 '/, ne1Gr/0 A
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OWNER NAME (L. F. MI),
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CONTRACTOR -FIRM NAME����
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CITY/COMMUNITY/STATE/ZIP
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CERTIFICATE OF EXEMPTION FROM WORKERS• COMPENSATION INSURANCE: -This section need not be completed if
the permit is for one hundred ($100) o, less. I certify that in the performance of the work for which this permit is
issued, l shall not -employ any -person in any manner so as to become subject to the Workers' Compensation Laws of
California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the.Workers;-.a ..,
Compensation provisions of the Labor Code, you most forthwith comply with such provisions or this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
-0 I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be
made in connection with work'authorized by this permit, and that no building structure, scaffolding, falsework, or
demolition or dismantling thereof; will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec 341, Title B'+
C:A.C.) r t
❑ As owner -builder, I will not employ anyone.to'do work which would require a permit from the Division of
Industrial Safety, as noted above, unless such person has.a permit to do such work from that division.
�7 Division of Industrial Safety Permit No.
Date Applicant
CONSTRUCTION LENDING AGENCY: I hereby affirm that there•is a construction lending agency for the performance
of the work for which this permit is -issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
•1 certify that I have read this application and state that the above information is correct. I agree to comply with all
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.
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF'ENTRY: I certify I have read this application and state that
the information given is correct: 1 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
upon the property for which I have applied for this permit for•the.purpose of making inspections. -
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPUPRMT n 4 i.A 9 1,27;;u om
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TOTAL
FEE ,, / • ��
BLDG. DEPT.
,VALUATION A'7s SSS Q�
NO.
OPERATION DATE INSPECTOR
NO.
OPERATION DATE I INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS.
1
Set Back
•33
Ventilation System
2
Ftgs & Frms
�� "'�
34
Plenums & Ducts
2A
Slab Grade
35
Furnace Comp art.
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 PSL.
❑
43
Final
10A
fireplace T.O.
❑
NOADDITIONAL INFORMATION
7/O / X
SEWAGE SYSTEM SIZE.& LOCATION _
11, Exterior Lath
12 .Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R••
Value
7A Walls (Batts) T�_
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/l
STREET.NAME
26 Power Pole
27 Conduit
28 Service Entrance
29.- - Wiring,
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final