0763 (BLCK)b
PERMIT APPLICATION q
-City of La Quinta
Department of.Building and Safety
This permit becomes void if work not commenced. within -180 days fromdate of is suance.,OR, if work has been suspended or a bandored for a period of .180 days.
ADDRESS'
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CERTIFICATE OF EXEMPTION FROM WORKERS'CCMPENSATION INSURANCE: This section need not be completed it
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 ce.,lify-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 inany manr er so asto become subject to the Workers' Compensation Laws of
and effect.
California.
License Class Lic. Number
Date Applic.-nt
Date Contractor -
NOTICE TO APPLICANT.,.If; after -making this Cer-ificatiot Exemption, you should become subject to.the Workers'
OWNER -BUILDER DECLARATIOW' .1 hereby affirm that I am exempt from the Coniractor's License Law for the
Compensation provisions of the,Labor Code,'YOL must forthwith comply with such provisions or this permit shall
be e 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 CERTFICATION:
such permit to file asigned statement that he is licensed pursuant to the provisions of the Contractor's License Law
0 1 hereby certify Inat no excavation live (5) ofrr3re feet 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 PTpfessions Code) or that he is exempt
made in connection with work authorized by thiE permit, and thit 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 dismantling1heieof, will be more than thirty-six (36) feet high. (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.Ax.)
0.1. as owner of the property, or my employees with wages as their sole compensation, will do the work, and the
O'As ownerobuilder, 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 -erson has a permit to do such work from that division.
Law does not apply town owner of property who builds', or improves thereon, and Who does such work himself or
; .. . . .. . . . . . . . V .
through his own employees. provided that such improvements are not intended or offered for sale. If, however. the
0 Division of Industrial. Safety Permit.No:
.building or improKemnt is sold within one year of completion, the owner -builder will have the burden of proving that
Date Applicant
he, did not build orimprove for_ the purpose of sale:).
CONSTRUCTION LENDING AGENCY: I hereby affian that theie is a construction lending agency for the performance
.0 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 (Ser—.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'stherew and who contracts for'tuch projects with a contractor(s) licensed pursuant to the
.-.
Contractor's License Law.).
Lender's Address
0 *1 am -exempt under Sec: B,- & P.C. (Attached,Certificate).
I certify that I have read this application and staie that the above information is correct. I agree to comply with all
'Date Owner
city and county ordinances and state laws relatiig to building construction, and hereby authorize representatives
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
SIDE
certificate of Workers' Compensation Insurance.. or a certified copy thereof (Seer 3800. Lab. C.). ,:-
Sig -nature of Applicant or Agent Date
Policy No Company
CERTIFICATE OFCOMPLIANCE AND AUTHORIZA10ON ORENTRY: I certify I have read this application and s6tethat
O:Certified copy is hereby furnished. %
the information given is correct. I agree tocomily with all state -laws and county ordinances relating to buidling
uilding Inspection Department or City Department.,
0 Certified copy is filed . With the City Building
uinta. Department of Building and Safety to enter
upon the property for which I have applied forhis permit for he purpose of making inspections.
Date Applicant
'
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPLICANT NAME'(L: F. MI`
ADDRESS'
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CITY/COMMUNITY/STATE/ZIP
JOB SITE ADDRESSISPACE__J
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CITY/COMMUNITY/STATE/ZIP
/4 -
BOK
PAG
PRC-
C J.TWN
I FING
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TRACT
LOT
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SB
TRACT NAME
OWNER NAME (L, F. MI)
CONTRACTOR -FIRM NAME
.ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE a
LICNC 9
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 0
LICNC 0
USE OF PERMIT
BL
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FSB
SSS'
SSB
RSB
OFC
ZONE ORD' V:
LOT SZ ci
END
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APPL/P.RMT �DA T E
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VALUATION
BLDG. DE
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
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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
PI P/I
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 • Service
32 Final