0767 (BLCK)PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
This permit becomes void if work nct commenced within -180 days from date of issuance. OR. it work has been suspended. or abandoned for a period of 180 days.
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am I icensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force
and effect.
License Class
Contractor
Lic. Number
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 a- county which requires a permit to
construct, alter. improve, demolish. or repair any structure, prior to its iSSLance, also requires the applicant for
such permit lotile asigned statement that he is licensed pursuant to the prowsions of the Contractor's License Law
(Chapter 9 (commencing with section 7000) of Division 3of the Business and Irofessions Code) or that heis exempt
therefrom and the ba'sis for the alleged exemption. Any violation of Sectior 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dol-2rs ($500.):
0 1. 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 thereo.i. 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,oiCimproverrint is sold within one year of completion. the owner-builaer will have the burden of proving that
he did not build or improve for the purpose of sale.).
0 1. as owner of the property, am exculsively contracting with licensed cor1ractors to construct the project,(Sec.
7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
builos or improves thereon. and who contracts for such projects with a Omtractor(s) licensed pursuant to the.
Contractor's License Law.).
0 1 am exempt under Sec. B. & P.C. (Attached Certificate).
Date Owner
WORKERS' COMPENSATION OECLARATION:A hereby affirm that I have a cL-tificate of consent to self -insure, or a
certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 38M. Lab. C.). -
Policy No. Company
• Certified copy is hereby furnished.
• Certified copy is filed with the City Building Inspection Department or City
Date Applicant
Department.
APPLICANT NAME (L. F. MI)
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ADDRESS
CITY/COMMUNITY/STATE/ZIP
JOB SITE ADDRESSISPACE 9
CITY/COMMUNITY/STATE/ZIP
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TRACT NAME
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE a
LICNC 0
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 0
LICNC
La
USE OF PERMIT 5, 1
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END
SIDE
CERTIFICATE OF EXEMPTION FROM WORKERSTOMPENSATION INSURANCE: This section need not be.completed if
the permit is for one hundred ($100) o. less. I certify that in the performance of the work for which this permit is
issued, I shall not employ any person in any manner so asto become subject to the Workers'Compensation Laws of
California.
Dale Applicant
NOTICE TO ARPLICANT:.Jf. after making this Certificate of Exemption, you should become subject to the Workers'
Compensation provisions of the.Labor Code, you must forthwith comply with such provisions or this permit shall
be deemed revoked. I
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
0 1 hereby certify that no excavation five (5) or mbre feet in depth into which a person is required to descend, will be
made in connection with workauthorized by this permit. and that no building structure. scaffolding, falsework, or
demolition or diimahtling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp Z An 2, Sec341, Tillell,
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 has a permit to do such work from that division.
0 Division of Industrial Safety Permit No.
Date Applicant
CONSTRUCTION LENDING AGENCY: I hereby affirm that there 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
I certify that I have read thisapplication and state that the above information iscorrect. I agree to comply with all
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
of this county to enter'dpon the above:mentioned property for inspection purposes.
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
construction. and authorize a representative of the City of La Ouinta Department of Building and Safety to enter
upon the property for which I have applied for this permit for the pu pose of making 'K's ti
7c ions.
Signature of Applicant or Agent
Print Applicant/Agent Name
APPUPRMT
DATE
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TOTAL
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VALUATION
BLDG.DEPT. I
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 Grad . e .35 Furnace,Cijm�art.
3 Steel 36" -Inlits� &'Outlets
4 Grout Blocks Combustion'Air
5 Bond Beams 38 Cdmpressor.
6 Roof Deck 39 Appll dlearance'
7 Framing 40 Fire.Damper
8 Vents 41, Smoke Detection- Device
9 Garage Fire Wall 42 Commercial Hood
10 Fireplace P.L. 43 Tinal
10A Fireplace T.O. OP'N ADDITIONAL INFORMATION -
NO.
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 -AP;ROVALS-
15 Ground Plumb
16 Water Piping
17 Rough -Plumb
18. Vents
19 Sewage Disposal
20 Sewer
21 Water Heater
-7
Water Softener
23 Water Ser vice
24 Gas Test
25 Final' ^�^��RA 0- 1 �^A�fi�ftl
E LECTR IC APPROVALS
26 Power -Pole
27' 'Conduit
28 Service Entrance
29 Wi
5ing
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
Tank Pit L. Line
REAR -OF PROPERTY LINE
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