0671 (SFD)'LICENSED CONTRACTORS DECLARATI
(commencing with Section 7000) of.Divi
and effect.
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, 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.lhe 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.):
0 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 thereon, 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 mprovem_nt 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 I, as owner of the property, 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 with a contractor(s) licensed pursuant to the
Contractor's License Law,).
0 1 am exempt under Sec. B. 8 P.C. (Attached Certificate)..
Date Owner cv
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.
... I ' -CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed it ..
ON: -I hereby' affirm that I am licensed under provisions of Chapter. 9 the permit is for one hundred ($100) o, less. I certify 113t in the performance of the work for which this permit is.
Sion 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'CompensationLaws of
California.
APPLICAHT-NAME
ADDRESS-
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TRACT NAME : /]nQ / Ole
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OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME
ADDRESS -
CITY/COMMUNITY/STATE/ZIP'
ARC/ENG FIRM NAME - ft
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N UCNC N -
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END
SIDE
Date Applicant
NOTICE TO APPLICANT: If,,after making this Certificate of Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code; you;must `orthwith comply with such provisions or this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
0 1 hereby certify that no excavation five (5) or more fee; in depth into which A person is required to descend, w ill be
made in connection with work authorized by this permi-, and that no building structure, scaffolding, falsework, or
demolition or dismantling theieof, will'be more than thir:.y-six(36) feet high. (Chap 3.2, Grp 2, An 2, Sec 341, Title B,
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 ias a permit to do such work from that division.
O•Division of Industrial Safety Permit No.
'Date' Applicant
CONSTRUCTION LENDING AGENCY: I hereby affirm that here is a construction lending agency for the performance
of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
certify that I.have.read this application and state that he above information is correct. I agree to comply with all
city and county ordinances and state laws relating to bLilding construction, and hereby authorize.representatives .
of this county to enter upon the above-mentioned proprty for inspection purposes.
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify l have read this application and state that
the information given is correct. I agree to comply withal) state laws and county ordinances relating to buidling
construction, and authorize a'representative of the Cit-' of La Ouinta Department of Building and Safety to enter
upon the property for which I have applied for this pernit for the purpose of making inspections.
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPUPRMT
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FEE
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
�'y7,2
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.
❑
NOON
ADDITIONAL INFORMATION
I�O1 f 814
4 ii rr SC�C�S >t
-
SEWAGE SYSTEM SIZE & LOCATION, .
11 Exterior Lath ,
12 Internal Lath
12A Drywall 07/
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
126 Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING APPROVALS
.15 Ground Plumb
16 Water Piping
17 Rough Plumb
18 Vents
19 Sewage..Disposal
20Sewer
21 Water Heater
22 Water Softener
23.- Water Service
24 Gas Test rij 51 T.
25 i Final
Tank Pit L. Line
-
ELECTRIC APPROVALS
REAR OF PROPERTY'LINE
t�
P/L,• nA_ P1
l%
STREET NAME
26 . Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32• Final