0837 GradingLICENSED CONTRACTORS DECL•ARATI
(commencing with Section 70001 of Divi
and effect.
' icense Class Lic. Number L
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, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
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 is exempt
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 (5500.)::.-
❑ I, as owner of 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 to an owner of property who builds, or improves hereon, and who does such work himself or
through his own employees. provided that such improvements are not intended or offered for sale. If, however, the
building or i mprovemnt is sold within one year of completion, the owner -builder will have the burden of proving that
he did not build or improve for the purpose of sale.).
0 1, as owner of the properly, am.exculsively contracting with licensed contractors 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 wish a contractor(s) licensed pursuant to the
Contractor's License Law.). w
0 1 am exempt under.Sec. B. 8 P.C. (Attached Certificate).
Dale • 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
0 Certified copy is hereby furnished.. ..
0 Certified copy is filed with the City Building Inspection Department or City Department..
Date Applicant
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.
• CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
ON: I hereby.affirm'that I am licensed under provisions of Chapter 9 the permit is for one hundred (5100) o, less. I certify that in the performance of the work for which this permit -is
sion Sof the Business and Professions Code, and my license is in lull force issued, I shall not employ any person inany mannerso asto become subject•tothe Workers' Compensation Laws of
i California.
APPLICANT NAME (L. F; MI)
}-
ADDRESS
CITY/COMMUNITY/STATE/ZIP ,
JOBS TE AODRESS/SPACE - ••
�yosD1,4 Z
CITY/COMMUNITY/STATE/ZIP
BOK'
7
PAG
3 3
PRC
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FIND
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TRACT
LOT _
7�
TOTAL
FEE
MOO
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,
TRACT NAME j �G �
OWNER NAME (L. F. MI)
CON RACTOR-F RM NAME .
ADDRESS
CITY/COMMUNITY/STATE/ZIP - -
PHONE •
LICNC •
'
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP - -
PHONE •
.LICNC•
..
USE OF PERMIT
BL
ZON
FSB
SS8
SS8
RSB
OFC
ZONE ORD •
_ LOT SZ _
END
SIDE
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificateof 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 cerjifythat noexcavationfive (5)ormore feet indepth into which apersonisrequired todescend, will be'
made in connection with work authorized by this permit, and that no building structure, scaffolding: falsework, or
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec 341, Title 8.
' C.A.C.)
0 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.
0 Division of Industrial Safety 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 permiVis issued (Sec. 3097, Civ. Q.
Lender'sName
Lender's Address
I certify that.l have read this application and state that the above information is correct. l agree to comply with all
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
of this county to en -m
ter upon the aboveentioned property for inspection putposes.
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 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
OA
APPVPRMT J/�T�
f'� �T �,fq 0E a T f9 5
. f-�,c�C�r is Fi ,c •�,�" 0 0
TOTAL
FEE
BLM DEPT.
VALUATION �� �`%• ®d '
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 Compa rt. .
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
16A
fireplace . T.O.
❑
NOON
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
25 Final
Tank Pit L. Line r
ELECTRIC. APPROVALS
REAR OF PROPERTY'LINE
P/L P)L
STREET NAME
26 Power Pole
27 Conduit
28 "Service. Entrance
.29 Wiring
29A Grounding Wire
29B; Bonding
30 Fixtures
31 Service
32 Final
INSULATION CE"RTIF ICATIOIV
-?9 -BIOS iQUyl- D;A `Z- 4,4 Q k 1 A) I A �,t al I z-
• Numoer anra Street City County
Suooivision Lot Numoer
DESCRIPTION OF INSTALLATION
ROOF
it
Material
Brand Name
r,
-r
Thickness (inches)
Thermal Resistance IR Valuel
EXTERIO WALL
//�
Material I �2 �+
/
Q - K/y S
t/
Thickness (inches)Z-
Brand Name W
Thermal Resistance IR Valuel
CEILING
lV
Batt or Blanket Type_
Brand Name
f
Thickness (incheess))g�
Thermal Resistant^ tR Valuel
Loose Fill Type
Brand Uame
Minimum Thickness (;nc/hest � J
Number of hags O `�
Weight per bagIb
;Area Covered Ih2) / _-;z_ 3o r 0-e
Thermal Resistance (R Valuel
3 b
FLOOR,ELEVATED
Material
Brand Name
Thickness finches)
Thermal Resisrance.iR Valuel
FLOOR, SLA/6///�1��
Q •. ,
Material ✓ �f1TW 1
Brand Name. ��Su-
c` a�
SCJ • C.-w-t—
t
Thickness finches)'/
Thermal Resistance tR Valuel
r
Width (inches) o�
FOUNDATION WALL
Material
Brand Name
Thickness :inchesl :
Thermal Resistance rn ': aiuel
DECLARATION
i hereoy certify ;hat the above insulation was :ns;alled in the building at* the above ioCation in conformance .%-stn the
current regwations settiny Energy Conservation Standards `or .new residential buildings ;located ;n Tale :a of the
California ac.min:strative Code). '
Lvt �`re, J-�R- �P✓ L( LA $ y I'
A
narat r :or :(Ber) ,.ense u^der! ..
S;jnaturidranlb Tine - 4ate
Suo•Contractor (insulation Aooticator) License Numoer
,nature ano rine .Date
W
a I
it
1
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