0601 (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, it work has been suspended or. abandoned fora period.of 180 days.
+` CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section nee
'LICENSED'CONTRACTORSDECLARATION: 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 t I
(commencing with Section. 7000) of Division 3of the Business and Professions.Cade, and my license is in full force e' issued. I shall nottemploy any person in anymanner so asto become subject to the Workers'Compensation Laws of,
and effect. California.
License Class - Lic. Number
Date' Contractor
OWNER'BUILDER' DECLARATION: I hereby affirm that I am exempt from 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. _
construct, after, improve, demolish, or -repair any structure, prior -to its issuance, also requires the applicant for
T such permit to file a signed statement that he.is licensed pursuant to the provisions of the Contractor's License Law
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) or that he isexempt
therefrom.and the basis for the alleged exemption. Any.violation of Section 7031:5 by any applicant -for a permit
'subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
O I, as owner of the properly, or my employees with wages as their sole compensation, will do.the work, and the wt
structure is not intended or offered.for sale (Sec. 7044: Business and Professions Code: The Contractor's License'
Law does not apply to an ownerof property who builds, or improves thereon, and who does such work himself or
through his ownemployees, provided that such improvements are not intended or offered for sale: If, however, the
building orimprovemntissoldwithinoneyearofcompletionAheowner-builder%yillhavetheburdenofprovingthat .
he did not build or improve for the purpose of sale.).
O I, as owner of the properly, am exculsively contracting with licensed contractorV.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.).
O' 1 am' exempt under Sec. . B. & P.C. (Attached Certificate):
Date + Owner,
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate 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:<+ -
O Certified copy is filed with the'City Building Inspection Department or'City' Department.
Date Applicant
APPLICANT E (L. F—MI)
ADDRESS
•7- / T O L''Iv � � 146. 4 L! �v `
MMUNI TY/STATEJZIP • '
CIJY/CI
JOSSJE�DD ESS/SPACE -
CITY/COMMUNITY/STATE/ZIP -
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LOT
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TRACT NAME
OWNER NAME (L. F, MI) -
CONTRACT �O�R�RM NAM,F�� /�
AGI /V
ADDRESS
CITY/COMMUNITY/STATE/ZIP '
PHONE #
-
LICNC 0
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE $
LICNC
USE OF PERMIT .
BL
ZON
FSB
SSB
SSB.
RSB
OFC.
ZONE ORD • -•
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LOT SZ
END'
SIDE
Date Applicant
NOTICE TO APPLICANT: It, 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:.
0 thereby ciartify thalno excavation five(5) ormorefeet in depth into'Whic6a person is required to descend, Will be
made in connection with'work.authorized by this permit, and that no building structure, scaffolding, falsework, or
demolition'6r'dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2 Grp.? Art 2, Se41, Title 8.
tA.6.) - yx Sec
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 Induslrial•Satety Permit No.
•//
Date r . ..f Applicant
CONSTRUCTION LENDING AGENCY: it hereby affirm that there is a construction lending agencyforthe performance
of the work for which this permit is issued (Sec"3097, Civ. G).
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 Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and statethat -
the information' given is -correct. I agree to comply with all state laws and county ordinances relating to buidling °t
construction. and authorize a'representative of the City of La Ouinta Department of Building and Safety -to enter
upon the property forwhich I have applied for this permit for the purpose of making. inspections.
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMTDATE
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NMI—
.. ;5•�iP
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Oil
1 '
® _0411 •5
" TOTAL'
FEE
VALUATION �` 6 All
BLDG. DEPT. - •-
OPERATION DATE INSPECTOR
BUILDING APPROVALS
NO.
OPERATION DATE
INSPECTOR
MECHANICAL APPROVALS
Set Back
33
Ventilation System
2
Ftgs & Frms
-7 744
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.
❑
NPON
ADDITIONAL INFORMATION
_
ff•-
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
STREET NAME
Pi
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire _
29B Bonding
30 Fixtures
31 Service
32 Final