0638 (RPL)PERMIT APPLICATION
�1 City of La Ouinta
Department of Building and Safety
This permit becomes void if work not commenced within,.180 daystrom date of issuance; OR, it work has'been, suspended or abandonedtfor a period of 180 days. .
AD ESS, 1
CERTIFICATE OF EXEMPTION FROM WORKERS, COMPENSATION INSURANCE: This section need not be completed it
'LICENSED CONTRACTORS DECLARATION: I .hereby affirm'that I:am.licensed. under provisions: of -Chapter 9
the permit is for one hundred ($100) o, less. Isertih' that in the performance of the work 'for which this permit is
,(commencing with Section.]000) of -Division 3of the Business and Professions Code, and my license is in -full force '.'.
issued, I shall not employ any person inany manner ;o as to become subject to the Workers' Compensation,Laws of
and effect.
California.
License Class Lit. Number
Date Applicant .
' Date ° Contractor -
NOTICE TO APPLICANT: Af, atter making this Certifi_cate.ol,Exemption, you should become subject to the Workers'.. .
OWNER -BUILDER DECLARATION: I he 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 ,
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
0 1 hereby�certify that no excavation five (5) or moreleet 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 pelmit, and that no building structure, scaffolding, falsework, or
therefrom and the.basis for the alleged exemption. Any.violation ol. Section 7031.5 by any applicant for a permit
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, An 2, Sec 341, Title 8,
subjects the applicant to a civil penalty of not more than live hundred.dollars ($500.):,.:
C.A.C.) ..` I •
0 I. as owner oI the property: or my, employees wilh:wages as their sole compensation, will do the work; and the.
0 As -owner -builder, I will not employ anyone to -Io 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 Satety, 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
CITY/COMMUNITY/STATE/ZIP
through his own employees, provided that such improvements are not intended or offered for sale. It, however, the
e, Division of Industria(,Safety Permit No.
building or improvernnt is soldwithin oneyeaLI.qf completion. the owner -.builder will.have the burden of proving that
-'-Date - Applicant -
he did.not build or. improve for.the purpose ofsale.). „
CONSTRUCTION LENDING AGENCY: I hereby affirm t rat 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. 3137, 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 pursuantao;the
.
Contractor's License Law.).
Lender's Address 1
' 0 1 am exempt under Sec. - B. & P.C.,(Altached Certificate).
I certify that I have read this application and state Itt.at the above information is correct. I agree to comply with all ,
Date ' Owner Y�.
.city and county ordinances and state laws relating b. building construction, and hereby authorize representatives
y
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. ora :.
.,END,. '
certificate of,Workers' Compensation Insurance., or a certified copy thereof (Sec. 3800: Lab: C.). . <
Signature ofApplicant or Agent Date
,Policy.No. _ Company,
CERTIFICATEOFCOMPLIANCEANDAUTHORIZATIONOFENTRY::IcertifyIhavereadlhisapplicationandstatethat...
O Certified copy is hereby furnished.n
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
O,Certified Copy is tiled with the Ci(y.Building Inspection 0 partmenj or' City,rt- -.
construction, and authorize a'representative of the City of La Ouinta Department of Building and Safety to enter
�Department
,t' S'`I. , .
'Date %�
upon the property'foi which I have applied for this permil,for the purpose of making inspections:
Applicant i �,. J n i rcV
Signature of Applicant or Agent Date
HL"7W, NI-j:�iMl <f! �. "5
AD ESS, 1
JOB/ 7 -ADD SS/SPACE,.iIC/ 6" V/ f./ /„''
'd
CITY/COMM/UNITY./STATE/ZIP,.
BOK
PAG
PRC
C
-.
TWN'
RNG
SE,"
S
%RACT��Z
LOT/_
Moo
se
TRACT NAME
OWNER NAME (L. F. MI) ,
CONTRACTOR -FIRM NAME _
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE.N
LICNC •
USE OF PERMIT .... .
81.
ZON
FSB
-SSB. '.
SSB.
RSB
OFC_
ZONEORD.0 -
;LOT'SZ
.,END,. '
SIDE
Print Applicant/Agent Name
APPUPRMT E/? C��I}
=�ij
IT
.4iAl;
, � 1
1
.'+ TOTAL " :
FEE •
�' �^✓, ...
•
BLDG.DEPT. VALUATION
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
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.
❑
OP`N
NO. .
ADDITIONAL INFORMATION'
GV0
'
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
• I
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
P/L P/1
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
.29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures t
31 Service
32 Final