0130 (MISC)y PERMIT APPLICATION ✓? q b
City of La Ouinta
Department of Building and Safety
This permit becomes void if work riot commenced within 180 days from date of issuance, OR, if work has been suspended or abandoned for a period of 180 days.
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9
CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE:. This section need not be completed If
the permit is for one hundred (5100) o, less. I'certity that in the performance of the work for which this permit is
(commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force
-
issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of
and effect.
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
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 city or county which requires a permit to
be deemed revoked. .
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law
0'I hereby certify that no excavation five (5) or morefeet in depth into which a person is required to descend, will be
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) or that heis exempt ,
made in connection with work authorized 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 applicant • for a permit
demolition or dismantling thereof;will be more than thirty-six (36) feet high. (Chap 3.2. Grp 2, Art 2, Sec341, Title B,
subject the applicant to a civil penalty of not more than five hundred dollars (5500.):
C.A.C.)
GA'1. as owner of the properly, or my employees with wages as their sole compensation, will do the work, and the
0 As owner -builder, I will not employ anyone to do work which would require a permit from the Division of w
structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Industrial Safety, as noted above, unless such person has a permit to do such work from that division.
Law does not apply to an owner of property who builds, or improves thereon, add who does such work himself or
through his own employees, provided that such improvements are not intended or offerbd for sale. If, however, the
0 Division of Industrial Safety Permit No.
building orimproverrntissold withihone year ofcompletion, the owner -builder will have the burden of proving that
Date Applicant
he did not build or improve for the purpose of sale.).'
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
0 I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec.
of the work for which this permit is issued (Sec. 3097, Civ. C.).
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
Lender's Name
Contractor's License Law.).
Lender's Address
exempt under Sec. B. 8 P.C. (Attache�reryifica r �
I certify that I have read this application and state that the above information is correct. I agree to comply with all
D team
7 �. —�
Owner _
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
.nwR Z ..' :,,
WORKERS'
WO KERS' COMPENSATION DECLARATION: I here%y affirm that I have a certificate of consent to self -insure, or a,.—
of this county to enter upon the above-mentioned property for inspection purposes.
of Workers Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. C.).
Policy No. Company
0 Certified copy is hereby furnished.
0 Certified copy is filed with the City Building Inspection Department or City
Date Applicant
Department.
APPLICANT NAME (L. F, MI)
ADDRESS 411
CITY/C:70 UNITY/STATE/ZIP
JOB SITEAr.DDDRESS/SPACE
CITY/COMMUNITY/STATE/ZIP
BOK
PAG
PRC
C
ila A7 171
TWN
RNG
SE
S
TRACT
LOT
TOTAL
FEE
eale} �/
MOD
SB
TRACT NAME
OWNER NAM�(L.F. MI)
���•�/�//Y�f��
CONTRACTP,R-FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE*
LICNC N
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE M
LICNC #
USE OF PERMIT
BL
ZON
FSB
SSB
SSB ,0"RSB
OFC
ZONE ORD N
LOT SZ
END
SIDE
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 to buidling
construction, and authorize a'representative of the City of -La Ouinta Department of Building and Safety to enter
upon ffie propertytor which Nave applyied�foF�this, permit f9orthe purpose of making inspections.]
Signature of Aipplicant'or Agent `� /� "Date
Print Applicant/Agent Name
APPUPRMT N111 0P R .y OATErp;Y 5
/w/a/C3,00.
ila A7 171
IIIVRL
City 01 La
TOTAL
FEE
eale} �/
VALUATION_ ys1
Arrow Printing 250/1-83 White: Finance Canary: Assessor Pink: Applicant Tag: Bldg. Dept. n�
W
w
NO.
OPERATION DATE INSPECTOR
NO.
OPERATION DATE 11VOECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
34
Plenums & Ducts
2A
Slab Grade
35
Furnace Compart.
3
Steel 16 v �G
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
:031W z-
25 Final
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
P/L P/I
t
STREET NAME
26 Power Pole
27 Conduit g
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final