0311 (AR)F
PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
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APPLICANT�NAME (L. F. MI(
ear b h�
ADDRESS ` ' -
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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.
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CERTIFICATE OF•EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed it -4
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am .licensed under provisions of Chapter 9
the permit 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, l shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of
and effect.
California.
- License Class Lic. Number
Date Applicant
.Date Contactor
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 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
be deemed revoked.
following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to
, 1
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 it licensed pursuant to the provisions of the Contractor's License Law.
-p 1 hereby dertify that no excivation five (5) oemdre feet in depth iAto which a person is requirid'to descend, will 6e
(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 the. alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
•.` demolition or dismantling.thereol, will be more than thirty-six (36) feet high.- (Chap 3.2, Grp Z Art 2, Sec 341, Title 8,
subjects the applicant to a civil penalty of not more than five 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
❑ As 'owner -builder, I will not employ anyone to do work which'v/ould 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 propertywho builds, or improves thereon, and who does such work himselfor
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through his own employees" provided that such improvements are not intended or offered for sale. If, however, the
O Division of Industrial 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 ).
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
❑ 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
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.).
Lender's Address
O 1 am exempt under. Sec. B.. B.P.C..(Attached Certificate).
I certify that I have read this application and state that the above information is correct. I agree to comply with all
Date Owner-
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
END
of this county to enter upon the above=mentioned property 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 , oracertified copy thereof ,(Sec. 3800.1ab. C.).
Signature of Applicant or Agent t Date
Policy No Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that'.
O'Cerufied copy is hereby furnished. •
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 Ins ection D✓epartment or -City " �` Department.
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construction. and, authorize a representative of the City of La Ouinta Department of Building and Safety to enter
!� r sgc �..' �-
APPlicantA
upon the property for which I have applied for this permit for the purpose of making inspections.
Signature of Applicant or Agent Date
APPLICANT�NAME (L. F. MI(
ear b h�
ADDRESS ` ' -
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CITY/COOMMUNITV//S�TA/TEE21P T/
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JOB SITE AODRE/S�S/SPACE '
CITYJ. COMMUNITY/STATE/ZIP -
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TRACT NAME
OWNER -NAME (L. F. ,MJ)—
CONTRI�C OR -FIRM M��a�//
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9
ARC/ENG FIRM NAME
ADDRESS '
CITY/COMMUNITY/STATE/ZIP
PHONE*
LICNC .
USE OF PERMI
BL
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SSB
SSB
RSB
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END
• SIDE
Print Applicant/Agent Name
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TOTAL
FEE
y• VALUATION 33�
BLDG.DEPT.
ELECTRIC APPROVALS
26
Power Pole
27
Conduit
28
Service Entrance, -
NO.
OPERATION DATE -
INSPECTOR
NO.
OPERATION DATE INSPECTOR
Bonding
30
I
BUILDING. APPROVALS
31
i'
Service
MECHANICAL APPROVALS
1 "
Set -Back
33
Ventilation System '
2
Ftgs & Frms
34
Plenums & Ducts
i 2A.
Slab Grade
35
Furnace Compart.
3
Steel
36
Inlets & Outlets -.
i4
Grout Blocks
37':
Combustion,Air"..-
' 5
Bond Beams -
38
Compressor
6,
Roof Deck
39
Appl. Clearance ".
7
Framing
e'2 3
40
Fire Damper
8
Vents
41
Smo.ke•Detection Device
• 1
9
Garage Fire Wall
42
Commercial Hood -
10
Fireplace P.L.
❑
43.
.Final ,
10A'
fireplace T.O.
❑
NON
ADDITIONAL'INFORMATION ~
'
n�%AIA^0 nvcbr�RA 01 7� o_ 1 nnwrfi^1L1
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 3
"18 Vents
19 Sewage Disposal
20 Sewer
21 Water Heater
22 Water Softener
23 Water Service.
24 Gas Test
25 Final
ELECTRIC APPROVALS
26
Power Pole
27
Conduit
28
Service Entrance, -
29
Wiring
29A
Grounding Wire
29B
Bonding
30
I
Fixtures
31
i'
Service
32
Final
Tank Pit L. Line
.. I REAR OF PROPERTY LINE.
STREET NAME