0489 (AR)LICENSED CONTRACTORS DECLARATI
(commencing with Section 7000) of Divi
and effect.
License Class Lic.Number
Date Contractor
OWNER -BUILDER DECLARATION: I hereby affirm that Cam 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) o r that he is exempt
therefrom and the basis for the alleged exemption. Any viplation of Section 7031.5 by any applicant fora permit
subjects he applicant to a civil penalty of not more than five hundred dollars ($500.):
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 o r.improvemnt 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 safe.).
❑ 1, 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.).
❑ 1 am exempt under Sec. B. & P.C..(Attached Certificate) --
Date Owner ffd" rGt 64C4_2y
W RKERS' COMPENSATION DECLARATION: I h re y 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. r • V. - , ..
'a Certified copy is filed with the City Building Inspection Department or City 7 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' COMPE IISATION 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 ($100) o• less. I certify Matin the performance of the work for which this permit is
sion3 of the Business and Professions Code, and my license is in full force r issued, I shall not employ any person in any manner scasto become subject to the Workers' Compensation Laws of
California.
APPLICANT NAM/E�(LyF�, MI)��
ADDRESS
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CIT�OMMUN� Y/STATE/ZIP '
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OWNg$ NAME (L. F Nut
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ADDRESS '
CITY/COMMUNITY/STATE/ZIP
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PHONE •
City Of La Quinta
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ARC/ENG FIRM NAME •�•
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE x
LICNC I
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USE OF PERMIT
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END
SIDE
Date Applicant
NOTICE TO APPLICANT: If, after making this Certifica-E of Exemption, you should become subject to the Workers'.
Compensation provisions of the Labor Code, you mut! forthwith comply with such provisions or this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
o 'l hereby certify that no excavation five (5) or more fet in depth into which a 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 or dismantling thereof, will be more than thrty-six (36) feet high. (Chap 3.2, Grp 2 Art 2, Sec341, Title B.
C.A.C.)
ri As owner -builder,') 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.
r,
O Division of Industrigl Safety Permit No.
.Date Applicant
6N' STRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
of thetwork for which this, permit is issued (Sec. 309:, Civ. Q.
Lender's Name
Lender's Address
I certify'that I have read this application and state tha., the above information is correct. I agree to comply with all
city and county ordinances and state laws relating,to 1 uilding 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 fF ENTRY: I certify I have read this application and state that
the information given is correct. I agree to comply wits all staWlaws and county ordinances relating to buidling
construction, and authorize a'representative of the Cly 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 Date
Print Applicant/Agent Name
APPUPRMT ! DATE
G=/-�G
/,_4
i
F
RE eEi If E13
JAN 16 1983
City Of La Quinta
TOTAL
VALUATION
BLDG. DEPT.
NO.
OPERATION DATE INSPECTOR
NO. OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
•
33 Ventilation System
2
F•tgs & 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.
❑
NADDITIONAL INFORMATION
O.
NO.
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 S
16 Water Piping
17 Rough Plumb
18 Vents
19 Sewage Disposal
20 Sewer
21 Water Heater
22 Water Softener
23 Water Seryice
24 Gas Test
25 Final
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
P/L Pel
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final