0413 (BLCK)PE APPLICATION ^ i ✓ I��V U
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.
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code: and my license is in'full force
and effect.
License Class Lic. Number X .
Date Contractor -
OWNER -BUILDER DECLARATION: Illhereby a1(•irm that I 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 pursuantlo the provisions of the Contractor's License Law.
(Chapter 9(commencing with section 7000) of Division 3 o1 the Business and Professions Code) or that he is exempt
therefrom and the basis (orythe alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicanbto,a civil penalty of not more than five hundred dollars (S500.):
01. as owner of 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, acid who does such work himself or
through his own employees, provided that such improvements are not intended or offered for sale. If, however, the
,building or i mprovemnt is sold within one year of completion, the owner -builder will have the burdenof proving that
he did not build or improve for the purpose•of sale.). 7.
O I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (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 contracts for such projects with a contractor(s) licensed pursuant to the
Contractor's.License Law.).
O 1 am exerppt under Sec. - .. B. 8 P.C. (Attached Certificate).
Date Owner
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. �g00. Lab: C.). '
Policy No. 7o l� �,`� �7Company,—*>714; F�'�l
CC
O Certified copy is hereby furnished. • 1•• �. - ..,
O Certified copy is filed.with the City Building InspectionlDepartment or�CiQt9 9 Department.
Date/f Applicant /f 24= itJ1644'LC I
APPLICANT 640A, F. Mn7D� �I•b (/r ! /.0,V
ADDRESSPa. /3OX 66
CITY/COMMUNITY/STATE/ZIP '
L A aalAf
JOB SITE ADDRESS/SPACE .-
%- Vr•7S �'RG c .tJD6i4LES
CITY/COMMUNITY/STATE/ZIP
L A QU/itJ T �
BOK
PAG PRC
C
TWN
FIND
•SE-
S
TRACT'
LOT
MOD
SB
'
TRACT NAME
OWNER NAME (L, F, MI)
CONTRACTOR -FIRM NAME .. ...
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE •
L.ICNC
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE N
LICNC •
-
USE OF PERMIT
BL -
ZON
FSB
SSB
SSB
RSB
OFC
ZONE ORD 0
LOT SZ
.END
SIDE
CERTIFICATE OF EXEMPTION FROM WORKERS WNIPENSAWON INSURANCE. This section need not be completed i
the permit is for one -hundred ($100) It, less: 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, atter making this Certificateof 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
be deemed revoked.
DIVISION OF, INDUSTRIAL SAFETY PERMIT CERTIFICATION: '
I I hereby certify tfiat 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 of dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2. Art 2; Sec34,1, Title B.
C.A.C.)
O As oWher-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.
O Division of Industrial. Safety Permit No.
Date Applicant
CONSTRUCTION LENDING AGENCY: I hereby affirmtliat•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
I 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
Print Applicant/Agent Name
Date
APPLIPRMT n 4 l - l ; ATE6 v—?
.64,ov,
PCfn1,V ,7' 70 94ez'4 Q —26
7 -
-TOTAL
TOTAL
FEE •
�® , j • lji c��
VALUATION 6 700 1OZ •
BLDG. DEPT.
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.
❑
OP'N ADDITIONAL INFORMATION
NO.
S A
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R"
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
PSL P)
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final