0310 (BLCK)APPLICANT NAME (L. F. MI)
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a
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 of 180 days.
•K •n.
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
LICENSED CONTRACTORS DECLARATION: I hereby affirm that dram licensed under provisions -of Chapter 9-
the permit is for one hundred.($100) o; less. I certify that in the performance.ol 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
v
_ Date Applicant
- Date R Contractor' — -_ , _
. •,r NOTICE TO APPLICANT: If, alter. making this Certificate of Exemption, you should become subject to the Workers'
OWNER•BUILDERDECLARATION: h hereby affirm -that 1 am exempt from the Contractor's License. Law' for the
;/-..Compensation provisions of the Labor Code, 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.
• • construcL'alter, improve,. demolish; or repair any structure, prior to its issuance, also requires the applicant for,
DIVISION OF.. INDUSTRIAL SAFETY PERMIT CERTIFICATION: <
such-permittofileasigned statementihatheislicensed puisuanttothe provisions ofthe Contractor's License Law ..
❑ 1 hereby certify1hat no excavation five (5) oi moie fee I 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 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.for a permit .
demolition or dismantling thereof, will be more than4hirty.six.(36) feethigh. (Chap 3.2, Grp Z. Art 2, Sec 341. Title 8, '
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
C.A.C.) '
❑ I. as owner of the property, or my,employees with wages•as their sole compensation, will do the work, and the
❑ As owner-builder,'I will'not employ anyone to do work which would require a permit from the Divisibn'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
r
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 one year of completion, the owner -builder will have the burden of proving that
Date Applicant_
he did,not build or improve for the purpose of sale.)., t..
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
13 1, 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 contractor(s),Iicensed pursuant to the
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Contractor's License Law.). J t
A '
Lender's Address
have information is
O l am'exemtit under Sec. B. B:P:C.,(Attached�Certificate).
,,,�� �p,l / Ce�IA �. L%
VDate / �Owner�'~4AkX
I certify that I read this application and state that the above correct.t agree to complywith all .
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
`7 /
of this county to enter upon the above-mentioned property for inspection' purposes. ,
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, ora
• :• .,
. certificate of Workers' Compensation Insurance% or a certified copy thereof (Sec. 3800. Lab. C.). (
Signature of Applicant or Agent Date
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
.❑ Certified copy is hereby furnished. ,. ,. .
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
• O Certified copy is filed with the City Building Inspection Department or City Department.
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 foi this permit for the purpose of making inspections.
Date Applicant
'
Signature of Applicant or Agent Date
APPLICANT NAME (L. F. MI)
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City ofta Quinta-
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VALUATION
BLDG. DEPT.
NO.
OPERATION 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.
❑
NON ADDITIONAL INFORMATION
/ Y
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 P)
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
36 Fixtures
31 Service
32 Final