0624 (RR)PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
cl �4
This permit becomes void it 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'COMPENSATION INSURANCE:. This section need not be completed if
- LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under. 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
I (commencing with Section 7000) of Divisiorf 3 of the Businessand.Professions Code, and my license is in full force
and effect. r
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issued, I shall not employ any person in any mannerso asto beco subject tothe Workers'Compensatio laws of
Californiaa..
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License Class V I �_ Lic. Number
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Datez/� Applicant tlzl � y� ��1
fContractor U S /'7 r r / }"z/
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Date " _ .:
; 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 the Contractor's License Law for the a
-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 repair 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
01 hereby certify that no excavation five (5yor more feet in depth into which a person is required to.descend, will be
- (Chapter 9(commencing with section 7000) of Division Sof the Business and Professions Code)or that he is exempt
made i6 connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or
therefrom and the basis for the alleged exemption." Any violation of Section 7031,5 by any applicant fora permit
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2. Grp 2, Art 2, Sec341,.Title8,
subjects the applicant to a civil penalty of not more than live hundred dollars ($500.): - ^ a;i c^..
C.R.C.)
' O I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the
❑ As owner -builder, I will.not employ anyone to do work which would tequire 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 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
ADDRESS
c' through his own employees, provided that such improvements are not intended or offered forsale. IL however, the-
❑ Division of Industrial Safety Permit No. .
building orimprovemntissold within one year ofcompletion, the owner -builder will have the burden of proving that
Date Applicant,
he did not build or improve for the purpose of sale.).
CONSTRUCTION LENDING AGENCY: I hereby.affirm that there is a construction lending agency for the performance
O I, as owner of the property, am exculsively contracting withlicensedcontractors 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
Lender's Name
builds or improves thereon, and who contracts for such projects with a contraclor(s) licensed pursuant.to the
SSB
-
Contractor's License Law.).
Lender's Address
❑ 1 am exempt under Sec. B. 8 P.C. (Attached Certificate).: •,
I certify that I have read this application and state that the above information is correct. I agree to comply with all ..
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city and county ordinances and state laws relating to building construction, and hereby authorize representatives
Date Owner
WORKERS' COMPENSATION DECLARATION: 1 hereby affirm that I have a certificate of consent to self -insure, ora
certificate of Workers' Compensatiorclnsurance-, or a certified copy thereof (Sec. 3800. Lab. C.).
Policy No. Company
❑ Certified copy is hereby furnished..
O Certilied copy is filed with'the City Building Inspection Department or City Department.
Date Applicant, ^
APPLI'C�'N*erNAMr�E(I. F. M'ly�/A
ADTs/„
CITYA((�_Ty`Ar�
JOB SITE ADDDRESS/SPACE
CITY/COMMUNITY/STATE/ZIP .. '
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TRACT NAME
OWNER NAME (L. F. MI)
COtNrA�OR.FIRM,NAMM
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CITY/COMM__ / flY/fISIT9 /ZIVP
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ARC/E KJ/ Y\ e�/4, /
ADDRESS
CITY/COMMUNITY/STAT ZIP
PHONE N
LICNC 0
USE OF PERMIT
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BIL •
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ZONFSB
SSB
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SSB
RSB
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ZONE ORD M
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END
SIDE'
of this county to enter upon 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
nd authorize a,representaJlve of the City of La Ouinta Department of Building and Safety to enter
upoXe pfoperty for w ic%l�hav pled Igrthis p for the purposetpf mak7'-.nsp ions.yC
°' ignature of'AppI''' I or Agent Date J T
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Print Applicant/Agent Name
APPU/P�RMT % DATE / /
RECEIVED
RR 24
TOTAL
FEE
Vr�/ rSS
VALUATION /8 /�.
BLDG. DEPT.
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS i
1
Set Back
33
Ventilation System
2
Ftgs & Frms
34
Plenums & Ducts.
2A
Slab Grade
35
Furnace Corripart.
-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 i
8
Vents
41
Smoke Detection" Device
9
Garage. Fire Wall
•42
Commercial Hood
10
Fireplace P.L.
❑
43
Final
10A
Fireplace T.O.
❑
NON
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ADDITIONAL INFORMATION 1
�(
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 f
ELECTRIC.APPROVALS
P/L
.REAR,OF PROPERTY LINE I
26 Power Pole
„P/L
>
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
STREET NAME
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