0849 (SFD)PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
This permitibecomes void if work noticommenced within .180 days from date of issuance: OR ffwork'has been suspended'o -abandoned fora 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 (S1O0).o, less. l certify that, in the performance of the work for which this permit is
(c9n!mencing,with Section 7000) ol[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 Pecome subject tothe Workers'CompensationLaws of
and effect. California.
License Class Lic. Number Date/ I
ADPlicant
Date Contractor NOTICE TO APPLICANT: 11, after making this Cerfi icate of Exemption, you should become subject to the Workers'
v Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit'shall
UILD
OWNER -BER DECLARATION: I hereby affirm that) am exempt from the Contractor's License Law for01e be deemed revoked. .
following reason (Sec. 7031.5., Business and'Professions Code: Any city or county which requires a'perm8 to
construct, alter, improve, demolish, or repair any structure. prior to its issuance, also requires the applicant for DIVISION OPINDUSTRIAL SAFETY PERMIT CERTIFICATION:
such permittofileasignedstatementthatheislicensedpursuanttotheprovisionsoftheContractorsLicenseLak. ❑ Iheretiycertifythatnoezoavationfive(5)ormorefeet indepth into which apersonisrequired todescend, wIII be
(Chapter 9 (commencing with section Mob) of Division 3 of the Business and Professions Code) 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 ;all e0ed.ekemption. Any violation of Section,7031.5 by any:applicant for a permit demolition ordismantling thereof, Will be morethanthirty;six (36) feet hipli.�(Chap 3.2, Grp ZArt2, Sec3/1, Title8.-.
subjects the applicant to a civil penalty of not more than five hundred dollars (SW.): C;A.C.j
❑ 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 require a permit from the Division of -
.structure is not intended or offered for sale (Sec. 7014; Business and. Professions Code: The Contractors License, Industrial*Safely, a;noted i Bove, uritess'such'person 6s;a permit to do such work from that division.
Law ,does not apply to an owner of property who builds, or improvestheteon, 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•. EIRIvision of lndustriaj Salety'Permit No.
baildingorimprovemntissoldwfthinone year ofcompletion,the owner-builderwillhavetheburden ofproving that Date. • Applicant
he did nS uild or improve for the purpose of safe.).. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lendingageneytor the performance
❑ 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 (SecAD97, Civ. C.).
7011. Business and, Professions Code: The Contractor's License Law does not, apply to an owner of property who - Lenders Name
builds or improves thereon„and who contracts for such projects with a cordractor(sj licensed',pursuantto the •.
Contractor's License Law.).. Lender's Address
❑ Lam exempt under Sea B. &,P..C. (Attached Certificate). I certify that 1 have read this application and state that the above information is correct; lagree to comply with all '
Date �” 14 - �� Owner city and county ordinances and state laws relatiogto building construction: and hereby authorize representatives
O ol.this county toeoter 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 certiffed;copythereof (Sec. 3800. Lab. C:):'
Polity No. Company -
O.Cerfffied copy is hereby furnished:
p,Cerbfied copy is flled•with the City Building Inspection Department'or'City' Departments'
Date, Applicant
APPLICANT NAME (L. F. MI
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ADDRESS -
Ods 400 �i✓nle P.os /�9cc #i2
CITY/COMMUNITY/STATE/ZIP
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. JOB SITE ADDRESSIBPACE
-#(P-400 6V467lis /zv .Si'�cE #i2
CITY/COMMUNITY/STATEMP
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Signature of Applicant or Agent Date
J CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I cehityI haveread thisapplicationarid statethat
the information given is'correct. I'agreeto:comply with all state laws and county ordinances,relating to buidling '
cons uctfon. and authorize.a tep esentative of the City of La Quints Department of Building and Safety to enter
U property for whjcUhave applied for this permit for the purpose of making inspections.
Signal o'f Appildrit or Agent Date
Print Applicant/Agent Name
M
DATE
/% Nli�,/ E�1 S% l.J C /l•1t>>31y.� /"it�•/i-")C !�•`�.r/l -
2 r'3�Jd'lLtsV�� I'L67n/S- ANS i 1''v'L / � f) /�i•E
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TOTAL .
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BLDG. DEPT.
VALUATION NO ��
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
Fin; Damper
8 .
Vents
41
Smoke Detection Device
9
Garage Fire Wall.
42
Commercial Hood
10
Fireplace P.L.
❑
43
Final
10A
Fireplace T.O.
❑
P, ADDITIONAL INFORMATION
N
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
25 Final
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
PSL P)
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final