0646 (SOL)v 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.
- I + CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
LICENSED CONTRACTORS DECLARATION: I hereby affirm that f am licensed under provisions of Chapter 9 the.permit is for.one hundred (8100) 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 as to become subject to the.Workers'Compensation Laws of '.
and effect.Californl '�
License. Class. -. Lic. Number - ` Date Applicant
Date •- Contractor'. NOTICE TO APPLICANT: If, after making this,Cerfificate of Exemption,'you should become subject to the Workers'
Compensation provisions of the Labor Code; you.must forthwith comply.with such provisions or this permit shall.
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the: Contractor's License Law for the w
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 permit to file asigned statement that he.is licensed pursuaqto the provisions of the Contractor's License Law 0 [hereby certity'thai no excavation five (5) oi 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) 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 thereof, will bemore than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341, Title8,
subjects the applicant to a civil penalty of not more than five hundred.dollars (5500.): CAC)
❑ I, as owner of the property, or my employees with wages as thei ,sole compensation, will do the work, and the A 0 As owner -builder, Iwill 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: pr.ovided.that such improvements are not intended or offered for sale. If, however, the ❑:Division of Industrial Safety Permit No. y
building orimprovemntissofdwithin one year ofcompletion. theowner-builder will have the burden of proving that . Date Applicant
he did not build or improve, for the purpose of sale.)..to : CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
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 anowner: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
0 I am exempt under Sec. B. 8 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 '•r 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.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure; or a
certificate of 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
0 Certified copy is hereby furnished. .the information given is correct. I agree to comply with aWstatefaws and county ordinances relating to buidling
0 Cerfified 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
Date Applicant upon the property for which I have applied for this permit for the purpose of making inspections.
APP,LJ~ICVNTtNA'ME /FLJ,X/V
A�'RESs/�+
CITY/ OMMUNI /STATE/ZIP
OR
JOB.SI%LE DESS/SP••�-• '
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J/I __11lJr��C'�Z
CITY/COMMUNITY./STATE/ZIP -
,A Q •
BOK
PAG
PRC
C
1
TWN
PING
SE
S
TRACT
LOT
MOD
SB
TRACT NAME
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME ..
ADDRESS -
CITY/COMMUNITY/STATE/ZIP
PHOLr
Y�• ��i�C '.��v`�
'LICNC •
ARC/ENG FIRM NAME ••
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE 0
LICNC 0
-
USE OF PERMIT
BL
ZON
FSB
SSB'
SSB'RSB
OFC .
ZONE ORD •
LOT SZ-
END
SIDE..
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMT 9 -n 0.4 / G _.S .
,A -Ax m /i T�nrp
//) S
104N151S S. v o
1
r. TOTAL
FEE • '
- S
. v
BLDG. DEPT. VALUATION
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION 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.
❑
NO
ADDITIONAL INFORMATION
-
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
'12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick 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/1
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring _
29A Grounding Wire
290 Bonding
30 Fixtures
31 Service
32 Final