0728 (RR)•PERMIT
ADDRESS' _ •• ,
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APPLICATION - 3 • • •.�
City of La Ouinta
Department of
Building and Safety ;
PAG..
PRC
• .. ... • :This permit be void. if work not commenced within 180 days'from date.oLissuance. OR,•if'work has been suspended or abandored fora period of 180 days. ..
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CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if., - ,
LICENSED CONTRACTORS DECLARATION: ;l hereby affirm'that I'ant'.licensed' under -provisions of Chapter. 9: -
+'the-permitis for one hundred ($100).o: Jess. I cer•,ity that in the performance of the work for which this.permit is,•:' '
:<tcommencing 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 mannarso asto become subjectto,the Workers' Compensation Laws of, _
and effect f� g//
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7 t4` Oil.
California. '
Applicant.
License Class Lic. Number -
Date-
�' ,r.
Date Contractor.' • •x
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NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
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OWNER -BUILDER DECLARATION:; 'I'hereby affirm that I am exempt from f6 Contractor's License Law, for the
Compensation provisions of the Labor Code, you:must forthwith comply with such provisions octhis permit shall
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following reason (Sec. 7031.5. Business and Professions Code: Any city or county. which requires, a permit to
be deemed revoked.
construct, alter, improve. demolish: or repair any structure, prior.to its issuance; also requires the applicant for-
DIVISION OF INDUSTRIAL SAFETY.PERMIT CERTI (CATION:
such permit, to.file a signed statement that he i.s. licensed pursuant to the provisions of the Contractor's License Law.
0 1 herebg certify, that rfo excavation five (5) or mc re feet in depth into which a person is required to descend, will be - _S
• (Chapter 9 (commencing with section.7000),of Division 3 of the Business and Professions Code) orthat he is exempt
made in connection.withwork"authorized by this'aermil, and that no building structure, scaffolding; falsework, or.'• ,
Aheretrom and, the basisfor-the alleged exemption. Any violation of Section 70331,5:by anyapplicant for a,permit
- •• demolition or dismantling thereof; will -be more then thirty-six (36) feet high. (Chap -3 2, Grp 2, Art 2, Sec341,•Title&
subjects the applicant to a civil penalty of not more lhan'five hundred dollars.(SSOO.):•
C.A:C.)'' "'
0.1. as owner of the property, or my employees with wages as their sole compensation, will do the work,and the r
❑'As owner -builder, I will not. employ anyone b do -work whichwould 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 parson has a permit to do.such work from that division.. ,- 4
Law. does: not apply to an owner of property who builds, or improves thereon, and who does such work himself or.
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'through his own:employees, provided that such improvements are not intended or offered for sale. lf, however; the •.
❑ Division of, Industnal Safety Permit No. y
-, building orimprovemntissoldwithinoneyeacofcompletion,theowner-builder•willhavetheburdenot.provinglhal
Date Appfica.it
he did not build or improvejor the purpose of sale.).
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CONSTRUCTION LENDING AGENCY:'( hereby aflirn that there is a construction lending agency'for the pe Rormance
O I, as owner of the properly,,am exculsively contracting with licensed contractors to construct the project (Sec: � ,
• ', : . of the work for which thistpermit is issued (Sec.. 3097, Civ. C.). - -
' -7044. Business and Professions Code:, The. Contractor's License. Law doesmot-applyto an owner of property who,
`(ender's Name
builds or improves thereon, and who contracts for, such projects with•a contractor(s) licensed pursuant to the'
Contractor's License Law.).. - ,. ?, -
LendeCs Address
❑ I am exempt .under.Sec: B. B.P.C. (Attached Certificate), '•
J ertify.that 1 have readtthis application and state that the above information is correct. l agree to comply.with all, , t„
'Date Owner
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, ora '
of this county to enter, upon the above=mentionee .property for inspection purposes. • '
�' �`� ff���L• T -?.? — 7 7 �J�,� -
—certificate of'Workers' Compensation'Insurance', or -a certified -copy thereof (Sec. 3800 Lab: C.)i
A
Signature of Applicant or Agent "� Date C
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATIaN OF ENTRY: I certify I have read this application and state that :
O Certified copy is hereby furnished., ..:+
the information given is correct. I agree to compl, with all state laws and county ordinances relating to buidling
MCertified copy is'liled With the City Building Inspection Department of:City Departmem
construction; and authorize a representative of the City of La Ouinta Department of Building and Safety to enter ?
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upon the property for which l have applied for tf s permit for; the purpose of making inspections. s '•
,Date Applicant
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- Signature of Applicant or Agent Date, f'
Print Applicant/Agent Name , t
APPLICANT NAME L. F. MI)
ADDRESS' _ •• ,
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CITY/COMMAUNIITYY//STATE/ZIP
JOB SITE ADDRESS/SPACE ,
s 3^37
CITY/COMMUNNIITY/STATE/ZIP
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TRACT NAME . - -
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CONTRACTOR -FIRM NAME
ADDRESS
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CITY/COMMUNITY/STATE/ZIP
.PHONE M --'
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.LICNC 0
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ARC/ENG FIRM NAME ,-
ADDRESS
CITY/COMMUNITY/STATE/ZIP ..
PHONE JI _.
[LICNC a
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USE OF PERMIT
81.
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END , SIDE
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•TOTAL
FEE,
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' •Y
G 1J 1
TL ~, VALUATION
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.
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43 ' Final
10A
Fireplace T.O.
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OP'NO. ADDITIONAL INFORMATION
�/ "S/7,23/S;
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
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
20 Sewer
21 Water Heater
22 Water Softener
23 Water Service
24 Gas Test
2Ei • Final
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
P/L P/1
STREET NAME
26 Power Pole '
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final