0764 (RPL)I I
` PERMIT APPLICATION
S/%
t City of La Ouinta
Department of Building and Safety
• This permit becomes void if work not commenced within 180 days from dale of issuance. OR, if work, has been suspended or abandoned for a period of 180 days: . .., '
r)i^ '•; .•.
CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATIONINSURANCE:-Thissectionneednotbecompletedif
' 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 70DO),of Division 3 of the Business and Professions Code, and my license is in full -force
issued, 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 tram the Contractor's License Law loathe
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 pursuant to the provisions of the Contra ctor'sLicense Law
01 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descind, will be
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) orthat he is exempt ;
made in connection with work authorized by this permit, and that no building structure, scaffold ing,'falsework, or '
sh therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit it.
demolition ordismantling thereof, will morethan six 36) feet hi h"(Cha 3.2, Grp 2, Art 2,Sec341. Title8,
9 thirty-six (
a•subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
„4 4 ;a„
O I. as owner.ol.the property, or my employees with wages as their sole compensation, will do the work, apd the, :.'
' ❑'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 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. r.•.
.' : .. • . , + r
• through his own employees, provided that such improvements are not intended or oifered,for sale. If, however, the .
, / e 0 Division of Industrial Safety Permit No.
building or improvemnt is sold within one year of completion, the owngr-builder will have the burden of proving that .
Date Applicant
he did not build -or improve,forthe 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 pontractors to construct the project fSec:
-of the work for which this permit is issued'(Sec. 3097, Civ. Q.
7044. Business and Professions Code: The Contractors 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
E
-O 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 "&rier ♦ ~ hN
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
♦ .
of this county to enter upon the abovernentioned property for inspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent ti self -insure, or a'''
END
certificate of Workers' Compensation Insurance% or a certified copy thereof (Sec. 3800. Lab. C.). :. +,-
Signature of Applicant or Agent Date'
Policy N.. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
O Certified copy is;hereby+furnished,
the information given is correct. Lagree to comply with all state laws and county ordinances relating to buidling
o Certified coy is tiled with the City Building Inspection- Department or City ' Depart ent... •
construction, and authorize a'representative of the City of is Ouinta Department of Building and Safety to enter
r/� e �.
Date `— ,+ �° f G A'plicant 1_11V1 s.E f!G>!% r
-. upon the property for which.) have applied for this permit for the purpose of making inspections.'
Signature of Applicant or Agent • Date
ME
A/1/h�/V�(
'ADDRESS
V IJ�S �W V
CITY/COMMUNITY/STATE/ZIP
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JOB SITE AOORESS/SIPACE 6 NOT•
CITY/COMMUNITY/STATE/ZIP s
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TRACT NAME
OWNER NAME (L. F, MI) ...
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CONTRACTOR -FIRM NAME
ADDRESS
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CITY/COMMUNITY/STATE/ZIP .. , ••
PHONE N •
4W
LICNC N
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ARC/ENG FIRM NAME
ADDRESS ..
CITY/COMMUNITY/STATE/ZIP ' • - �-
PHONE N
LICNC-N
USE OF PERMIT
BL
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FSB
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SSB ;
RSB,
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ZONE ORD N,
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END
' SIDE, -,
Print Applicant/Agent Name
APPVPRMT �;4ZAI 6
7: o or-- 1 3 s ct F7' o'F
_584 4 ,0,06�QDajIJ
PIAN %e,c! &"1/, Da
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City of La Quinta
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3 U
r. Y. VALUATION
BLDG. DEPT.
..t
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
1rilets & 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
1 Final
10A
Fireplace T.O.
❑
OP'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)
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 PiI
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29• Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final