0308 (BLDG)PERMIT APPLICATION LJ0.a
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 fc a period of. 180 days.
ADDRESS
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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
the permit is for one hundred ($100) o, less.,) certify teal 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.
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 affirm that I am exempt from the Contractor's License Law for the
Compensation provisions of the Labor Code, you mus 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
construct• alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICA-ION:
• suqh•permitlo file asigped statement that he is licedsed.pursuant to the provisions of the Contractor's License Law
❑ 1 hereby certify that do excavation five (5) or more feet in depth into which a person is required to descend, will be
(Chapter 9(commencing with section.7000) o1 Division 3,of the Business and Professions Code)orthat heir exempt
made in connection'with work authorized by this perm t, 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 disinantlirig thereof, -will be more than th zty-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 live hundred dollars (S500.):
C.A.C:)-
❑ I. as owner of the properly, or my employees with wages as their sole compensation, will do the work, and the
4 ❑ As owner -builder•, 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 persoe has a permit to do such work from that division.
Law does not apply to an owner of property who builds, or improves thereon, avid who does such work himself or
CITY/COMMUNITY/STATE/ZIP
through his own employees, provided that such improvements are not intended or offered for sale. It, however; the
0 Division of Industrial Safety Permit No.
building orimprovemntissoldwithinoneyearofcompletion.theowner-builderwillhavetheburdenofprovingthat
Date Applicant =
he did not build or improve for the purpose of sale.).
CONSTRUCTION LENDING AGENCY: I hereby affirm tha there is a construction lending agency for the performance
❑ I, as owner of the property, am exculsively.contractiny with licensed contractors to construct the project (Sec.
of the -work for which this permit is issued (Sec:309a 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
SSB
- Contractor's License Law.)...._
Lender's Address
' ❑ Ia`m'exempt•under,Syec C� — ^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 ` ��'
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
LOT.SZ
of this county to enter upon the above-mentioned prcperty for inspection purposes.
• WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent. to self -insure, or a,
END
• '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 Or ENTRY: I certify I have read this application and state that
❑ Certified copy is hereby furnished. _ - ,. ..
the information given is correct. I agree to comply wile all state laws and county ordinances relating tobuidling
O Certified'copy is filed with the Oy Building Inspection Department or City Department. -
construction, and authorize a'representative of the C. -,y 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
AP .LICANTT�NAAMEE (L, F`• MI) �yj //�/t ` •'
ADDRESS
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C TY CJ/YOMMUNIT�yJ®STATE/LIP
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TRACT
LOT
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SB
TRACT NAME
OWNER %Q'NAME (L. F. M1) .. '
CONTRACTOR -FIRM NAME -
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 1
LICNC •
-
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 11
LICNC e
'
USE OF PERMIT
BL
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FSB
SSB
SSB
RSB
OFC
ZONE ORD N
LOT.SZ
END
SIDE.
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMT
/
DATE
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Al
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.e/*Per
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1983
QLOnta
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TOTAL
FEE
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/
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.
NO.
ADDITIONAL INFORMATION
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/1
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final