0694 (RR)PERMIT APPLICATION
Cityof La Ouinta
Department of Building and Safety
ThWilormit becomesvoid it work not commenced within 180 days from date.ofissuance, OR, i1`work,has been suspended,or abandoned fora period of.180 days.
LICENSED CONTRACTORS DECLARATION:71 hereby.affirm that I amAicensed under provisions- of*Chapter 9
(commencing with Section 7000).of (Division:3 of the Business and Professions Code, and my license is intull4orce
and effect
License Class Lic. Number
Date Contractor; -
OWNER-BUILDER'OECLARATION: I hereby affirm that I am' exempt froiWthe Contractor's License Law for the
following reason (Sec. 70314. Business and Professions Code: Any city, or county which requires a.permit to
construct, alter, improve, demolish, or repair anystructure, prior toitsissuance, also requires the applicant.for
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractors License Law
0a;%T,9tcessMseMk%withsection'-7000} ofawisionSotthisSusihti samRdlesat0MC%ft0TthMhaisextmpt
therefrom.and the basis for the alleged exemption, jtny violation of.Section 7031.5 by any applicant for a permit
subjects the applicantao a civil penalty of,normorOtthan five hundred dollars (5500.):
11 I. 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 ContractorsLicense
Law does not apply to'an.owner of property who builds, or improves thereon, and who does such work himself or
ihrougti his own employees, provided that such improvements are not intended or offered for sale. If, however, the
building or improvemm is 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 Contractor's License Law does notapply to anowner 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.):
01 am exemptunder 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
ceitificate,of Workers' Compensation insurance•, or a•cerfified copy thereof (Sec: 3.800. Lab. C:).,
Policy No. Company
-0 CertNiad eopyis hereby furnished.
Q Certttied copy isIII ed ith the City Building insp De a min Clty: Dep rent.
Dare�u " Applicant."` L
APPLICA J, NAM .(L -F. W) 1 ! r
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ADDRESS •- - .
CITY/GDI�IMUNITY/STA IP
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JOB TE ADDRESS/SPACE _ --
CITV/COaOWNITY/BTATE/ZIP -
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TRACT NAME ..
OWNER NAME (L. F. ee0 -
CONTMC IRM NAME -
ADDRESS
CITW COMMUNITY/ST�ATjE/ZIP -
ARCA NG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP -- .
FNOHE a
LICNC e
USE OF PERMIT
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SSB
SSB
RSB
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END
91DE
CERTIFICATE OFEXEMPTION FROM WORKERS'COMPENSATIONINSURANCE.- This section need not becomplited it
the permit is forone hundred ($100) a. less. I certify that in the performance of the work for which this, permit is
issued. I shall not employ any person in any manner so as to become subject to the Workers' Compensa0on Laws of
California.
• Date Applicant
NOTICE TO APPLICANT:: If, after making this Certificate of. Exemption; you should become subject to the Workers'
Compensation provisions' of the labor Code, you must forthwith complywith such provisions or -this permit shall
be deemed revoked.
DIVISION OF INOUSTRIAL'SAFETY PERMIT CERTIFICATION:
0 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 with work authorized by this permit and that no building structure, scaffolding.talsework, or
demolition,or dismantling thereof, will'be more than thirty-six (36pfeethigh. (Chap 3Z Grp Z Art Z, Sec 341, Title B;
C.A.C.)
0 As owner -builder, I will'notemploy 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.
0 Division of Indgstrial Safety Permit No.
Date Applicant.
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is'a construction lending agency for the performance
o4the workdor which this permit is issuedi(Sec. 3097, Civ. C.):
Lender's Name
I certify that l have, read this application and state that the above Information,is correct..) 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 l have'read Misapplication and state that
the information given is correct: I agree to comply with:all state laws and county ordinances relating to buidling
construction, and authorize a representative of Me City of La Ouinta Department of•Building. and Safety to enter
upon the property for which.Chave,applied for thin permit foc.the purpose of making Inspections.
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
VALUATION 1 •
BLDG. DEPT.
NO.
OPERATION I 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.
❑
OPIN
NO.
ADDITIONAL INFORMATION
v
SEWAGE SYSTEM. SIZE & LOCATION
11 Exterior Lath
12 Internal Lath�2/2�C/
12A Drywall
13 Finish Grade
INSULATION Thick Value e
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
p/L P/I
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final