0703 (PAT)PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
Thiwpermirbewmes void if.work not commenced within 180 days from date of issuance. OR', if work -has been suspended or abandoned for period of 180 days.
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
LICENSED CONTRACTORS DECLARATION: I herebi affirm that I am licensed under provisions of. Chapter'I the permit is for one hundred MOO) o, less:.) certify thatin the performance 011ie work for which this permit -is
(commencing 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 in any manner so as to become subject to the Workers' Compensation Laws of
and effect. California.
License Class Lic. Number_
DateContractor
'OWNER -BUILDER DECLARATION: I hereby at firm that I am exempt from the Contraclor's'License'WWfor the
following reason (Sec. 70.31.3. Business and,professions Code: Any city. orcounty 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 thecontractor'sLicense Law -
(Chapter 9(commencing with section 7000) of Division 3 of the Business and Professions Code) or that he is exempt
therefrom, and the basis for'thealleged exemption. Any violation.of Section 7031;5-by.amy applicant for a permit.
subje a applicant to a_civil penalty of notmore than five hundred dollars,(E500:):,
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 or improvemnt is sold within one yearof completion, the owner -builder will have the burden of proving that
he did not buildbr improve for, the purpose of sale.).
O f as owner of the property, am exculsively contracting with, licensed contractors to construct the project (Seca
7044. Business and Professions: Code: The Contractor's License. Law does not apply to ;an,owner'of property who
builds or -improves thereon, and whacontractsHor, such projects with a contractor(s) licensed pursuant to the
Contractor's License Law);
01 am exempt under Sec. - ..B..3 P.C. (Attached Certificate).
date' Owner [_
WQ KERS' COMPENSATION DECLARATION: I ereby affirm,thatI have a certificate of. consent to self -insure, or'a
certificate of Workers' Compensation Insurance, ora certifiedcopythereof (Sec. MOO. Lab. C.).
Policy No. Company
0 Certified copy is hereby:furnished..
O'Cerlifted copy is filed with the. City Building. Inspection Department or City Department.
Date Applicant
APPLIGM.T NA (L. F,.
ADDRESS -
CITY OMMUNITY TATE/ZIP
JO6_JjTE ADDRESS/SPACE - -
CITY UNITY/STATE/ZIP
BOK
PAO
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TMM
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TRACT
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SB
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TRACTJ&WE
CONT'WTOR-FIRM NAME
ADDRESS
CITY/COMMUNRY/STATE/MP
PHONE' a
LICNC e
ARC/ENO FIRM NAME -
ADDRESS ..
CITWCOMMUNIT1r/STATE/LP -
PHONE a
LICNC e
USE OF PERMIT
BL-
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SSB
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I END.'-
SIDE'
Date Applicant
NOTICE TO APPL1CANT:Af; after making this Certificate.of.Fxemption, you should become subject.to the Workers'
Compensation provJisions of the Labor Code, you must forthwith comply With such provisions or this permit shall
be deemed revoked. -
DIVISION OFADUSTRIAL SAFETY PERMIT CERTIFICATION:
O I hereby certify that no excavation five (5) or morefeet 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 thirty-six (36) feethigh. (Chap 32, Grp Z Art 2,Sec341, Title B,
C;A.C:)
O'.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.
p.DiyiI.
sion o(Industrial,Safety Permit No.
Date Applicant
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agencyfor the pertorrriance
of the work,for which this perm@ is issued (See. 3097, Civ: -CJ. '
Lender's Name
Lender's Address
I certify that`t have read this application and state that the above information incorrect. 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 upon the above-mentioned property for Inspection purposes. '
Signature of, Applicant, or Agent Date
• CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify l 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 Ouirna.Departmenbof Building and Safety to enter
upon the property for which I have applied forthis:permit for the purpose of making inspections.•
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPLNRMT ?
el/17/ to coif 1/sY���L'� 7 n
CGCG'tZ11 _S"GtJIJ d/?
1
r•
TOTAL
FEE •
y�
BLD0. DEPT.
VALUATION
NO.
OPERATION I DATE INSPECTOR
NO.
OPERATION I DATE INSPECTOR.
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs•& Frms
34
Plenums & Ducts
2A
Slab Grade
35
Furnace Comport.
3
Steel
36
Inlets & Outlets
4
Grout Blocks
37
Combustion Air
5
Bond Beams
38
Compressor
6
$soWeck
i ?
39
1 Appl. Clearance
7
Framing
40
Fire Damper
B
Vents
41
Smoke Detection Device
9
Garage Fire Wall
42
Commercial Hood
10
Fireplace P. L.
❑
43
Final
10A
fireplace T.O.
❑
NPON
ADDITIONAL INFORMATION
J , /
(J e �,tVSC
_
SEWAGE. SYSTEM.SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick. 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
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
P/L P/I
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32• Final