0279 (SATT)APPLICANT NAME (L. F, MI)�y�•� �t�� y
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i
PERMIT APPLICATION
City
of La Ouinta
'Department of
Building and,Safety w ,
I
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 WORKERSCOMPENSATION 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) It. 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 Woikers'CompensationLaws of
and effect.
California.
License Class Lic. Number
�•� f
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 must forthwith comply with such provisions or this permit shall
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 a signed statement that he is licensed pursuantto the provisions ofthe Contractor's License Law
b I hereby certify that no excavation five (5) or mbii feet in depth into which a person is required to descend, w if I be
(Chapter 9(commencing with section 7000) of Division Sof the Business and Professions Code) orthathe isexempt
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
subjects the applicant to a civil penalty of not more than five hundred dollars (S500.):
'demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2. Grp 2, Art 2, Sec341, Titlefl,
O I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the '+
C.A.C.)
structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License
O 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.
Law does not apply to an owner of property who builds, or improves thereon, and who does such work himself or
BLr
through his own employees, provided that such improvements are not intended or offered for safe. 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.).
SSB
O I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec.
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.).
7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
buil(1s or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the
Lender's Name
Contractor's License Law.).
Lender's Address
O 1 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 (honer
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a
of this county to enter upon the above-mentioned property for inspection purposes.
certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. C.).
Policy No. Company
Signature of Applicant or Agent Date
O Certified copy is hereby furnished.
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
O Certified 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 f' �' % Applicant
upon the property for which 1 have applied for this permit for the purpose of making inspections.
Signature of Applicant or Agent Date '
1.1
Print Applicant/Agent Name
APPLICANT NAME (L. F, MI)�y�•� �t�� y
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Plurbing Fee
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TRACT NAME
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IWOR-FIRM NAME
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~.. TOTAL
ARC/ENG FIRM NAME
ADDRESS
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CITY/COMMUNITY/STATE/ZIP
PHONE II
LICNC N
USE OF PERMIT
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RSB
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END
= SIDE
Arrow Printing 250/1-83
APPL/PRMT }1 0 2 - 7 (DT�83 .
Flezat iV build 3o523 scr• LP of
Comb • •
.....
MwhnAcal Fee
19000
Plan Cieck Fee
N ;330,20
Omistr=t:icn Fee
:: f-.';500:00 --
kal Fee
ix11,i. Fee
'• ,9 *07 ..
Plurbing Fee
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Pr'� Dery GS�d ft
{7�3�.00
600.00
1.
OR
of La
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~.. TOTAL
White: Finance Canary:'Assessor Pink: Applicant Tag: Bldg. Dept.
VALUATION $1290.629.00
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION DATEINSPECTOR
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
42 I?
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
N O.
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall Wz mn 7-
t3 Finish Grade
INSULATION Thick Value
7A Walls (Batts)
12B Ceiling (Batts)
126 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 / -2j' fj
25 Final
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
PSL PyI
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
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