0680 (RR)PERMIT APPLICATION
City of La Quinta
Department of Building and: Safety
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This permit becomes.void'ifwork notcommenced within 180 days from,date of; issuance,. OR, if work:has been suspended or abandoned for a period of 180 days.
CERTIFICATE OF D (EMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
LICENSED CONTRACTORS DECLARATION: I hereby affirm that Iam :licensed •ullderprovisions of Chapter,9 the•permit Is forone hundred ($10D)o, less:.tcertify that.in the performance of.the work for which this permit is.
(commencing with'Section 7000) of Division'3 ofthe Business And Professions Code, and my license is in full force Issued, I shall not employ any person in any mannerso as to become subject tothe WorkersS Compensation Laws of -
and effect. Caliloroia.
License Class Lic. Number Date Applicant
Date ' Contractor
OWNER-BUILDEWDECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for the
following reason (Sec. 7131.5,' Business and Professions Code: Any cIlly or county which requires a permit4o
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 pursuant to the provisions of the Contractor's License Law
(Chapter 4 icommencing with sec fion 7000) of Division 3 of•the Business and Professions Code) orthat he is exempt
therefrom and the.basisfor the alleged exemption. An violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil, penalty of,notimore than five hundred dollars (5500:);
❑ I, as owner of th@property or my employees with wages as their sole compensation,mill,dothe work; and the r
structure is not intended or offered for Sate (Sec.,7044, Business and Professions Code: The Contractor's.Licenss
Law does not apply to anmwnerof property.whobuilds, or,improves thereon, aodwhodoes such work himself or
through hi5ownemployees, provided that such improvements are not intended or offered forsale. If, however, the
building or-improvemnt is soldwithin one year of coMpiption, the owniir-builie,r will liavetheburden ofproving that .
he did not build or improve for ihe,purpose of sale.). -
0 I, as owner of the property, am exculsively contractingwith licensed contractors to construct the project (Sec:
7044. Business and.Professions Code: The, Contractor's'License Law does riot apply an owner of; property woo
builds or improves thereon, and who contracts 'for such projects with a comractor(s)dicensed,pursuant'to the
Contractor's License.Law?).
❑ Lam exempt under Sec. B. & 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-, ora certified copy thereof (Sec: 3800. Lab. C.):,
Policy.No; - Company -
❑'Cettified copy is hereby furnished.. a,
❑'Ceriifiea copy'is filed with the CityBuildingJnspection Department or.City. Department.
Date Applicant
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NOTICE TO APPLICANT:. It, aftermaking this Certificate of, Exemption„you should become subject to the Workers'_.
Compensation provisions of the Labor Code, you must forthwith comwith such wsuch provisions or this permit shall
be deemed revoked. ” '
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: -
El:I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be
made in connection withwork authorized by this permit, and that no building structure, scaffolding, falsework, or
demolition or dismantling thereof, will'be more than Ihirty,siZ.(36)'fee1 high. (Chap 3.2, Grp Z Art 2, Sec341, Title 8,
O7 Aa owner -builder, I; will not employ anyone'to do work�which'would require aipermit froin.the Division of
Industrial Safety; as°noted above, unless'such person has a permit to do such work from that,division.
p Division of',Industrial SafetyPermit No.. -
Date Applicant!
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency forthe performance
of.thework,for which'this permit is issued (Sec. 3097, Giv. C.).
Lender's Address
I certify.thatl 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 countyto'enter upon the aboveinentioned,„property for inspection^purposes.
Signature of'ApplicanforAgent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATIOWOF ENTRY certify) have readthisapplicationand state that
the information given,is correct. i agree to comply wfth all state laws and county ordinances relating to butdling
constructlon,,and,authori2e,a'represeotative of the City ohla Quinta Department of Building and Safety to enter
upon )pro erty for which have applied tor, permit for•the purpose $ making” "pee ionj�
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Signature of,Applicant or Agent Date
Print Applicant/Agent Name
VALUATION[/i
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VALUATION[/i
%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.
❑NON
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
PL P/
STREET'NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final