0643 (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,'if work has been suspended or abandoned'for a period of'180 days. _
AOD ESS!
3
,- 010 we/,j�(
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if '
• LICENSED CONTRACTORS DECLARATION: I hereby affirm that l: am licensedunder 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 7000) of Division 3 of the Business:and. Professions Code, and my license is in full force
:issued, I shall not employany person inany manner so asto become subject tothe Workers' Compensation Laws of -
and effect.
California.
License Class Lic: Number
_. Date Applicant
' Date Contractor"'
h+r
NOTICE TO.APPLICANT: If, after.making-this Certificate of Exemption, you should become subject,to the Workers
r:
OWNER -BUILDER DECLARATION: I hereby affirm that I 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.
be deemed revoked.
following reason (Sec. 7031.5. Business -and Professions Code: Any city or'county.which requires a permit to
,
construct. alter, improve. demolish, or iepair 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's License Law
O'.Ihereby .certify. that no excavation five 1 5) or more feet in depth into which a person'i6 required to descend, will be
(Chapter9(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 thg basis for the alleged exemption. Any violation oftSection.7031.5 by any applicant fora permit
'dimolitionor dismantling thereof, will be more than thirty-six (361 feet high. (Chap 3.2, Grp $'Art 2; Sec341, Title B.-
.subjects
subjectsthe applicant to a civil penalty of not more than five hundred dollars ($500.):
C'A.C.)
O I. as owner of the property,•or my employees with wages as their sole compensation, will do the work, and the
Y:'O As owner -builder, I will not employ anyone to do work which'would require a permit fromthe Division of
' structure is not intended or.offered for sale (Sec. 7044: Business and Professions, Code: The Contractor's License
lndustriatSaiety, 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 -
CITY/COMMUNITY/STATE/ZIP
through his own employees, provided that such improvements are not intended or offered for sale. If, however, the ',
-O Division. of Industrial Safety Permit No.
buildingorimprovemntissold within one year ofcompletion. the owner -builder will have the burden of proving that,
Date Applicant "
Itd'd•Ito build or improve for the purpose of sale:).
BL
CONSTRUCTION LENDING AGENCY: .1 herebyaffirm that there is a construction lending agency for the performance '
O 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
builds or improves thereon, and who contr cis for sucprojects,with a contractors) licensed pursuant to the
l f�< '
Ld'Name
Lender's
.Name
Lender's Address
• Contractor's License Law.). <�ij /
%+ '• B P:- Certificate).
I that I have this and that,the above information is [agree to '
11I amyexemp pnde'r:Sec3 - — f8! . (Attached
/ 7
certify read application state correct. comply with all
/`. IT4ner
'Date11
city and'countyordinances and state laws relating to building construction, and hereby authorize representatives
-
-of thiscounty to enter upon the above=mentioned:propehy for inspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that.1 have a certificate of consent to self -insure, or a
.. ' . • ' .
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 applicationand state that
• .O Certified copy is hereby furnished. n. :t
'.the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling rF`•
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,
a. _
upon the property for which I have applied for this permit -for the purpose of making inspections.
Date .Applicant
APPLIC• NTjNA"E61�p,NI1.. / y./O 1--(-21-
G:E� /
AOD ESS!
3
,- 010 we/,j�(
p�
CITY/C-OMMMMUNIIV'I'/S]._ +1 l��
JO
_.5TP .6S/SPACE
CITYCCOMM UN,F•/STATE/ZIP
BOK
PAG
PRC
�C•
TWN"
RNG
SE
S
'TRACT"
LOT
?:
MOD
Se
-
TRACT NAME -
OWNERNAME(L. F. MI) • ^ ••
ADDRESS
CITY/COMMUNITY/STATE/ZIP -•- -
PHONE • -
-
LICNC 0
ARC/ENG FIRM NAME
ADDRESS .
CITY/COMMUNITY/STATE/ZIP
PHONE Ir
LICNC •
.•
USE OF PERMIT
BL
-ZON
FSB
SSB.
SSB'
RSB.
OFC
ZONE ORD a
LOT SZ
-
-.END ' ;
SIDE' '
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPVPRMT
r
•
Dli; iispi
City of - r a
TOTAL*
FEE
?:
VALUATION --FA A�10E�
BLDG. DEPT.
NO.
OPERATION DATE
INSPECTOR
NO. OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33 Ventilation System
2
Ftgs & Frms
3
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
40Fire Damper
8
Vents
41 Smoke Detection. Device
9
Garage Fire Wall
42 Commercial Hood
10
Fireplace P. L.
❑
43 Final
10A
f=ireplace T.O.
❑
NPON ADDITIONAL INFORMATION
i
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 PyI
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final