0369 (SFD)LICENSED CONTRACTORS•DECLARATI
(commencing with Section 7000) -of Div
and effect.
LicenseClass Lic. Number
Date
Contractor
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt,from the Contractor's License Law forthe
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 signedstatement that he is licensed pursuant to the provisions ofthe ContraPtor'sLicensel-aw -
(Chapter 9(commencing with sei:110 7000) o1 Division 3 of the Business and Professions Code) orthat heisexempt
therefrom and the basis for the alleged exemption. Any violation Section 7031:5 byany'applicant for a, permit
subjects the applicant to a civil penalty of not more than five hundred dollars (5500.):
0.1• as owner.,of the property, osmy employees with wages as their sole compensation. will do the work. and the
structure 1s 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, and who does such Work himself or.
through his own employees; provided that such improvements are not intended or offered for sale. It, however, the
building or improvemntis sold within one year of completion, the owner -builder will have the burden of proving that
he did not build or improve for the, purpose of, sale.,).
0 I, as.owner of the property, -am exculsively contracting with licensed contractors to construct the project (Sec.
7044; Business and Professions'Code: The Comractor-s.license Law does 1x11 apply town owner of property who -
builds or Improves thereon; and who contracts for such projects with a contractor(s) licensed pursuant.to Me
Contractor's License.Law.). .
0 1 am ,exempt under Sec:l B. 3 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',rara certified ,copythereof (Sec. 3600. -Lab. C.).-
Policy.No., Company
0 Certified copy Whereby furnished.
00 rtified copy'is Iii Xith'th� eCity ' Building Inspection Dep nt�or city R'` /De/partment.
ate z2 / PPlicant��
PERMIT APPLICATION
City of La Duinta
Department of Building and Safety
This permitbecomes void il,work not commenced within' 180 days from date of issuance; OR, it,work has been suspended or abandoned for a period of 180 days.
-
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed it
ON: I hereby affirm that 1- am .licensed under provisions of Chapter9: 'the permit is for one hundred ($100),6; less. I certify that in the performance of the work for which this"permit is '
ision3ofthe Business and Professions Code, and'mylicense isinfull force - issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of
California.
APPLI6A�IT"NAME . R.. F. )
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- SIDE
.—NOTICE.TO APPLICANT: if, after making this Certificate of Exemption„ you should become subjectto the Workers'.'
Compensation provisions of the Labor Code. you must forthwith comply with.sugh provisions or MIs permit shall'
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
o Ihereby certify that noexcavationfive(5)ormorefeet Indepth into which aperson isrequired todescend, Will be
made in connection with work authorized by this permit, and lhatno building structure; scaffolding• falsework, or
y,•;;demolhionor dismantling.thereof, will , be more thin thirty-six (36)4iel high. (Chap 32. Grp Z Art 2, Sec 341. Title 8, '
0 As owner -builder, I will notemploy anyone to do work which would require a'permit from the Division o1 -
Industrial Safety, as, noted ' above, unless such ,personhas.a permit to do such work from that division.
d Divisionof Industrial Safety Permit No.
Date Applicant
CONSTRUCTION LENDING AGENCYi Ihereby affirmthat thereisacoostroctfonlendingapeneyforiheperformance
of -the work -for which this permitis issued (Sec. 3097; Civ: -C.).
Lender's_Name
Lon der's Address
I.certify that] have.read this application andstate that the above information is correct. I agree to comply with all
cityand 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 Agent Date
CER TIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify l have read thisapplication and state that
the information given,is correct. l agree to comply.with all state laws and county ordinances relating to buidling
construction, And authorize a,iepresentativeof the City of La Quints Department of Building and Safety to enter '
up n.th ertyfor which I, have applieE for.this permit for the purpose making inspections.
Signature of:Applicant or Agent Date
Rim Applicant/Agent Name
APPL/PRMT a X111 9"
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City, ®f La , uin a
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VALUATION ��dr
of
NO.
OPERATION DATE INSPECTOR
NO. OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS ,
'1
Set Back
33 Ventilation System
2
Ftgs & Frms
-72,01'34
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
/ /3 °
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.
❑
NON ADDITIONAL INFORMATION
/ r
✓��� /' f/�ri (� .
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath „3
12 Internal Lath
12A Drywall. 7-
13
13 Finish Grade
INSULATION Thick • R"
Value
7A Walls (Batts)
126 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 -- Q L
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/
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final