0730 (BLCK)LICENSED ,CONTRACTORS DECLARATI
(commencing with Section 71X10) of Divi
and effect.
' License Class Lic, Number Date Applicant .
Date Contractor- - NOTICE TO APPLICANT: It, after making this Certificate of Exemption; you should become subject to the Workers'
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for the .. Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall
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 CERTIFICATION:
j. such permit to file asignedstatement thatheislicensed pursuant tothe provisions ofthe Contractor's License Law - 01 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) or that he is exempt made in 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 five hundred dollars ($500.): CAC)
0 1. as owner of the properly, or my employees with wages as their sole compensation, will do the work, and the , -0 As owner -builder, I will not employ anyone to do work which would 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 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 s
through his own employees, provided that such improvements are not intended or offered for sale. It, however, the . O Division of Industrial Safety Permit. No.
building orimprovemntissold within one year ofcompletion. the owner-builder,willhave the burden ofproving that Date- Applicant
he did not build or improve for the purpose.ol sale.).
iCONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance'
0 I, as owner of the property, am exculsively contracting with licensed contractors 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 contractor(s) licensed pursuant to the
Contractor's License Law.). Lender's Address
i O 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
Date Owner K. city and county ordinances and state laws relating to building construction, and hereby authorize representatives
of this county to enter upon the above-mentioned property for inspection purposes.
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.). 4: - • Signature of Applicant or Agent Date
Policy. No. Company CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I'have read this application and state that
(. LY, Certified copy is hereby furnished., _ - the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
/t construction, and authorize a,representative of the City of La Ouinta Department of Building and Safety to enter.
❑ Certified copy is tiled with the City Building Inspection,Department or6ity Department. .
�' f �� �•�i i - / -1�, 1y ; upon the property for which I have applied for this permit for the purpose of making inspections.
- Dai 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 issuanceAR, 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
ON: 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
Sion 3 of the Business and Professions Code, and my license is in full force issued, I shall not employ any person in any mannerso asto become subject to the Workers'CompensationLaws of
California.
APPLICANT NAME (L. F, MI) � i
n k(A\.
ADDRESS '
CITY/COMMUNITY/STATE/ZIP
JOB SITE ADDRESS/SPACE
CITY/COMMUNITY/STATE/ZIP '
BOK
PAG
PRC C
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TRACT
LOT
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TRACT NAME
OWNER NAME (L. F,,t1)�--
CONTRACTOR -FIRM NAME
ADDRESS -
CITY/COMMUNITY/STATE/ZIP
I—
LICNC
'
ARC/ENG FIRM NAME Y �_ --•
ADDRESS PP o
CITY/COMMUNITY/STATE/ZIP
PHONE*
LICNC P 6
USE OF PERMIT
BL
ZON
FSB
SSB
SSB'
RSB
OFC
ZONE ORD 6
LOT SZ
.END
SIDE: .
a
2'
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMT n 7 .1GATE
7 i•= (.� i -I �`G epi �, 4 �,�c _�..
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1 OO i C)� 41 4— �icx
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TOTAL
FEE
BLDG. DEFIT
VALUATION �vt� LV
ELECTRIC. APPROVALS"'
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
298 Bonding
30 Fixtures
31 Service
327 Final
REAR OF PROPERTY. LINE
STREET NAME _
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION DATE INSPECTOR
BUILDING.APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System,
2
Ftgs & Frms
5
tlW
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.
❑
ADDITIONAL INFORMATION
NO
11
Exterior Lath
12
12A
.Internal Lath
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
SEWAGE SYSTEM SIZE .& LOCATION
Tank Pit L. Line
ELECTRIC. APPROVALS"'
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
298 Bonding
30 Fixtures
31 Service
327 Final
REAR OF PROPERTY. LINE
STREET NAME _