0623 (BLCK)PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
" This permit becomes void if work not commenced within 180 days from date of issuance, OR; if work has been suspended or abandoned for a period o1.180'days.
LICENSED CONTRACTORS DECLARATION: I herebyaffirm that •f am licensed under provisions of Chapter .9
(commencing with Section 7000) o1 Division 3 of the Business and Professions Code, and my license is in full force:
and effect.
License Class Lic. Number.
Date Contractor
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt'irom the Contractor's License Law for the
following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to -
construcL alter; improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
- such permit totile asignedstatement that heis-licensed .pursuanttotheprovisionsoftheContractor,sLicense Law
(Chapter 9 (commencing with section 70001 o1 Division 3 o1 the Business and Professions Code) or that he is exempt ,
therefrom and the basis for the alleged exemption. Any.violationof Section 7031.5 by any,applicant for a permit • . .
subjects the applicant to a civil penalty ol,not more than'five.hundred dollars ($500.):
❑ I. as owner o1 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 loan 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: If, however, thee+
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.).
1611. as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec.
7004, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improvesithereon, and who contracts for such projects with a contractor(s) licensed pursuant•to the
Contractor's License Law.).
O 1 am•exempt unitSeC B\8 P�C. (Attached•Ceitificate)_:--
Date G. 1 lJ Owner�k 4fiNJaI2 2 12 .\
WORKERS' COMPEN TION DECLARATION: I hereby affirm that I have atcertificate of consent to self -insure, or a
certificate of Workers"Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. C.)..
Policy No. Company
O Certified copy is hereby furnished. , r.
❑ Certified copy is filed with the City Building Inspection Department or City Department.
Date Applicant
APP.LR NT NAME (L, f,-MI)W
f1�7�/��
ADDRRESP —/ Q ) 0
CITY.•CCOM`� NIITTVATE/ZIP '
JOB SQE^,!D'OfiF�SS/2-ACE
CITY/COMMUNITY/STATE/ZIP
BOK
PAG
PRC I
C
TWN
RNG
.SE"
S
TRACT
LOTMOD
TOTAL '•
FEE
,SB
TRACT NAME -
OWNER NAME (L, F. MI) '
CONTRACTOR -FIRM NAME
ADDRESS '
CITY/COMMUNITY/STATE/ZIP
PHONE-.
LICNC M
ARC/ENG FIRM NAME - ••
ADDRESS
CITY/COMMUNITY/STATE./ZIP '
PHONE •
LICNC •
'
USE OF PERMIT
BL
ZON
FSB
Sse
Ss8
RSB
OFC
ZONE ORD .
LOT SZ
END
SIDE
CERTIFICATE OF EXEMPTION FROM WORKERS .COMPENSATION INSURANCE. This section need not be completed if '
the permit is for'one hundred ($100) o. less: I certity.that in the performance of the work for which this permit is
issued'
1shall not employ any person inany manner soastobecome subject tothe Workers'CompensationLaws 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 comply with such provisions or this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
O l 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, fafsework, or
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341 Title8.
C.A.C.)
O 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.
❑ Division of Industrial 5afety Permit No.
Date' - Applicant
CONSTRUCTION LENDING AGENCY: I 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.y
Lender's Name
Lender's Address
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 Applicant or Agent Date
CERTIFICATE OF'COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
the information given is correct. I agree to comply with all state laws and county ordinances relating for 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
APPLIPRMT
PF.C' 17 i ,(34111-
' fj'�//1- Dist/ � �0,��'. S' � • 3' o
TOTAL '•
FEE
.7 .. t) c+e
VALUATION
BLDG,. DEPT.
I ._
NO.
OPERATION DATE INSPECTOR
NO.
OPERATION DATE INSPECTOR
BUILDING APPROVALS. _'
MECHANICAL APPROVALS
'1
Set Back
33
Ventilation System "
2
Ftgs & Frms
S o
34
Plenums &Ducts
2A
Slab Grade
35
Furnace,Compart.
3'
Steep
.36
Inlets &Outlets.
4
Grout Blocks
y
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.
❑NDN
ADDITIONAL INFORMATION
SEWAGE SYSTEM SIZE.& LOCATION
1? 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
PLUMB ING-APPROVALS
15 Ground.Plumb
16 Water Piping
17 Rough Plumb
18 ' Vents
19 Sewage- Disposal.
20 Sewer
21 Water Heater
22Water 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