0482 (BLCK)PERMIT APPLICATION
F City of La Ouinta
Department of Building and Safety
This permit becomes void it work not commenced within 180 days from date of issuance, OR, if work has been suspended or abandoned for a period -of 180 days
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CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am' licensed. under provisions .of Chapter.9
the permit is for one hundred ($100) o, less. I certify that in the performance of the work for which this permit is '
(commencing with Section 70001 of Division 3of the Business and Protessions'Code: and my license is in full force,
issued, I shall not employany 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: IL after making this Certificate of Exemption, you should become subjectto the Workers'
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's LicenseLaw lor.the
Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall
be deemed revoked. '
following reason (Sec. 7031.5. Business and Professions Code: Any city or county which, requires a permit to
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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.'sLicenseLaw ..
0 1 hereby cirtifi. that no excavation five (5) or more feet in depth into which a person is required to des cend. w it I be
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) orthat he is 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 fora permit, ,
, .4demolition or dismantling thereof, will be more than thirty-six (36) feet high: (Chap 3.2. Grp 2, Art 2, Sec 34 Title 8.
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
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O I. as owner of the, property. pr my employees with wages as their sole compensation, will do the work, and the
O As owner•builder, I will not employ anyone -to do work which would require a permit'from the Division of
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, and who does such work himself or
ADDRESS
through his own employees; provided that such improvements are not intended or offered for sale. If, however, the -.
❑ Division of Industrial Safety Permit No.
building or improvemnt is sold within oneyear of completion, the owner -builder will havethe burden of provingthat
Date Applicant
he did not build or improve for the purpose of sale.). r,, - , - -
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
• O 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
Lender's Name
builds or improves thereon, and who contracts for such projects with a contractors) licensed pursuant to the
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Contractor's License Law:). ����y , L� �i /�,� �r,
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Lender's Address
am exempnder Sec !' "� 'v�
t uB. 8 P.C-(Attached Certifcate�
I certify that I have read.this application and state that the above information is correct. I agree to comply with all
Date `1— / �' 'rOwner '_ t.
city and county ordinances and state laws relating to building construction, and hereby authorize representatives r
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of this county to enter 'upon the above-mentioned property for inspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that,l have a certificate of consent Co self -insure, or
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certificate of Workers' Compensation•Insurancel; or a certified copy thereof (Sec. 3800. Lab. C.).
Policy,No. Company
❑ Certified copy is hereby furnished. •, .
O Certified copy is filed with the City Building Inspection Department or City Department.
Date Applicant
APPLICANT NAME (L. F. MI)r. _
7T'A44Fa 44AnAj L>A
ADDRESS -
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CITY/COMMUNITY/STATE/ZIP
JOB SITE ADDRESS/SPACE '
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OWNER NAME (L. F. M1)
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP ,
PHONES
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L•ICNC 0
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ARC/ENG FIRM NAME.
ADDRESS
CITY/COMMUNITY/STATE/ZIP ,
PHONES
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USE OF PERMIT
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END
. SIDE
Signature of Applicant or Agent k. Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify) 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'"ich I have applied for this permit for the purpose of making inspections.
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPUPRMT � rI DATE
I
TD 8U/Gd
3 7027 � !�
-� .�E•�� ,iT To ,BviL
ya,2 i.cl
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TOTAL
FEE
VALUATION /� C,6 '
BLDG.DEPT.
NO.
OPERATION DATE
INSPECTOR
NO. OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33 Ventilation System
2
Ftgs & Frms
p
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.
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NO ADDITIONAL INFORMATION
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4
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.
PSL Pi
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final