0402 (BLCK)PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
This permit becomes void if work not commenced. within 160 days from date of issuance. OR, if work has been suspended or abandoned fora period of 180 days. . . ' .
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under, provisions of Chapter 9
(co mmencing. with Section 7000) of Division 3 of the Business and Professions Code. -and my license is in full force
and effect.
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
the permit is for one hundred.($100) o, less. I certify that in the performance of the work for which this permit is
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issued. I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of
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 from the Contractor's License Law for the 1� Compensation provisions of the Labor Cade, you must forthwith comply with such provisions or this permit shall ..
following reason (Sec. 7031.5. Business and Professions Code: Any.cily or county which requires a permit to be deemed revoked. n
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for w DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
such permit to file a signed statement that he is licensed pursuantlo the provisions of the Contractors License Law. 0:1 hereby certify'tKat no excavation five (5) or more feet indepth into which a person is required to descend, will be '
(Chapter 9(commencing with section 7000) of Division 3 otthe Business and Professions Code)or that he is exempt ;made in connection with wdrk authoriied 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 applicanttgr,p permit demolition or dismantling ther0f, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341, Titlefl,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): C.A.C:)
l4e s 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 Contractor's License.
Law does not apply to an owner of property who builds, or improves thereon, avid who does such work himself or
through his'own employees, provided that such improvements are not intended or offered for sale. If, however• the
building orimprovemntissold within one year ofcompletion. the owner -builder will have the burden of proving.that .
he.did not build or improve for the purpose of sale).,
❑ 1, 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 not apply to an owner 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.).
I
' ❑ I am exempt under Sec \B`: 8 P;C. (Attached Certificate .
Date r` 'A r / . — Owner ����. P t 4 5 `A d?,4h".. R __
WO KERSCOMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to sell -insure, or a
certificate of Workers' Compensation Insurance , or certified,copy thereof (Sec..3800: Lab. C.).
Policy No. Company
O Certified copy is hereby furnished.
❑ Certified copyis.filed with the City Building' Inspection Department or City' Department.
Date Applicant
APPLICAf1TJNAM_Q�,'A
ADDRESS
// _
CITY/COJ.IMUNI TY. TA� ZIP/7F-
JOBSITEADDRESS/SPACE
CITY/COMMUNITY/STATE/ZIP
BOK
PAG
PRC
C
TWN
RNG
SE
-S
TRACT
LOT
MOD
SB
TRACT NAME
OWNER NAME (L. F. MI) -
CONTRACTOR -FIRM NAME
p
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE a
LICNC
ARC/ENG FIRM NAME '
ADDRESS -
CITY/COMMUNITY/STATE/ZIP -
PHONE 0
LICNCC/A
C f " / el
BL
ZON
FSB
SSB
SSB,
RSB
OFC
ZONE ORD*.
LOT SZ
END
SIDE
-0 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.
O'Division of Industrial Safety Permit No.
Date Applicant.
r
CONSTRUCTION LENDING AGENCY: 1 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.).
Lender's Name
Lender's Address
I certify that I 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 county to'enter upon the above-mentioned property for inspection purposes.
Signature of'Applicani or Agent bate
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify l 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
construction, and authorize a' representative of the City of La Ouinta Department of Building and Safety to enter
upon the property for which I have applied for this permit for the purpose of making inspections:
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMT - ni'3 DATE
c
TOTAL
• FEE
VALUATION} ecj�'
BLDG. DEPT.
t
NO.
OPERATION DATE
INSPECTOR
NO.
• OPERATION DATE INSPECTOR
BUI LDING'APPROVAL•S
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'
f=ireplace T.O.
❑
NPON
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
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
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