0497 (SPA)APPLIC7Iu{�I��J`LnN, NAML
ADDRESS
. PERMIT
APPLICATION
f a City of La Ouinta !
Department of Building and Safety
PAG
PRC
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 18Odays.• °•"
•. - - ,• -. - ... ++.• i -Y:; -
,CERTIFICATE OFEXEMPTION FROM WORKERS! COMPENSATION INSURANCE: Thissection'neednot becompleted if
LICENSED CONTRACTORS DECLARATION; d hereby affirm that I arn' licensed under provisions of: Chapter..9
the_permit is'for'one hundred ($100) o, less. I certif-•.ihat-in the'performance of the work for which -this permit is
'(commencing with Section 7000) of Division 3 of the Business and Professions Code: and my -license iIs.•full force-, >+
issued. I shall not employ any person in any manner so as to become subject tothe Workers'Compensation Lawsof
and effect.- - �. C,/J
California.
License Class Li�c �
Date Applicant
�✓'Number
'Dater Contractor,.-, IL s. :7::/d �.1 _ NOTICE. TO`APPLICANT:.If, after making this Certificate of Exemption, you should become subject to the Workers .:._
U.• '
ER DECLARATION:''I-herebyaffirm that it anivexempt-from'the Contractor's License Lawlor the
OWNER -BUILD -
- Compensation provisions of _the Labor Code, you must forthwith comply with'such provisions or this permit shall '. z
• 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:
',such permit to file asigned statement that he is licensed pursuant to the provisions of the Contra ctor'sLicense Law
.O.Ihereby'ceitity that noexcavationfive(5)ormortifeetin'depthinto which aperson isiequiredlodescend,will be
' (Chapter 9 (commencing with section 7000) of Division 3 of the Business and Processions Code) orthat heisexempl •
_
made in connection with work authorized by this permit, and that no huildingstructure, scaffolding; falsework, or
therefrom and the basis for the alleged.exemplion. Any violation of Section 7031.5 by any applicant for a permit
demolition or dismantling thereof, will be more than thirty-six (36i feet high: (Chap 3.2, Grp 2, Art 2, Sec341; TitletI...+k;
subjectsthe applicant to a civil penalty of,not more than five hundred dollars ($500:):
C.A.C.) " "f ' _ '•"'Y
0 1, as.owner of,the property, or -my employees with wages as their sole compensation, will do the work,'and the: ;,.::
:. '0 4owner-builder, Ywill not -employ anyone to Jo work which would require4 permit from the Division of i
'; • structureis noGintended or,offered for sale (Sec. 7044; Business and'Prefessions.Code: The Contractor's License ; .
IndusfriM Safety, as 'noted abbve,--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-
= m -
through his own employees, provided that such improvements are not intended or offered for sale. ll, however; the:
0 Division of. Industrial Safety Permit No.
' building or.improvemnt is sold within one year of completion, the owner -builder will have the burden of proving;that.
Date' Applicant.-
pplicant`he
hedid not build or improve for the purpose of sale.). ;
CONSTRUCTION LENDING AGENCY: thereby affirm that there is a"construction lending agency for the performance -
0 l,'as owner of the property, am•exculsively contracting with licensed contractors to construct the project(Sec:. a -
•. of the work for which this permitis issued' (Sec. 3.197, civ. Cq).
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 A
- : 0 I -am exempt -under Sec. ''"`" ' " "'' `- '- - . B:.B P.C. (Attached Certificate).-..'...:
'I certify.that I have,read,this application and state bat the above.information is correct. l agree -to comply with all
:Date Owner '
'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-pu'rposes.v P
WORKERS' COMPENSATION DECLARATION: I hereby affirm thatl have a certificate of consent to self -insure, ora:'
,
' certificate of Workers' Compensation Insurance , ora certified copy thereof (Sec. 3800; Lab: C.).'
- - " Signature of Applicant or Agent n � - ' Date'` -
Policy No. Company,
•"�
c CERTIFICATE OF COMPLIANCE AND AUTHORIZATIOC OF ENTRY: I certify I have read this applicationandslatethat '
0 Certified copy. is hereby furnished.. .• y;u' ' a :
theAnformatiomgiven is correct. I agree to comply vith all state laws and county ordinances relating to buidling- .�
"0 Certified'copy is filed with'the City Building Inspection Oepartment-or City - Department. -
construction, and authorize a'representative of the'•City of La Ouinta Department of Building and Safety to enter +
upon the property for which I have applied for.thie permit for the purpose of making inspections.
Date Applicant
s
Signature of Applicant or Agent Date
—
Print Applicant/Agent Name 1
APPLIC7Iu{�I��J`LnN, NAML
ADDRESS
CITY/COMMUNITY/ST TF,JZ�.� -
JOB SITE ADDRESS/SPACE ..
CITY/COMMUNITY/STATE/ZIP
CQBOK I!!�'ff
PAG
PRC
C .
TWN - -
RING
TRACT
LOT
M.D.
TRACT NAME -
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME •• 't ..,
ADDRESS - -
CITY/COMMUNITY/STATE/ZIP.
t
{�
ARC/ENG FIRM NAME
ADDRESS - -
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC V
USE OF PERMIT •_ '
BL r
ZON
FSB
SSB
SSB,
RSB,
OFC
OZONE ORD N:
LO 'SZ
" END";
'. SIDE
APPUPRMT. %_ATE G . / .' �'i r • .. -
l/lee
,s2rlJ�r 3y, o0
a •
.y .
n ,
r ✓ "' r TOTAL'
FEE
c i . a •} + _ • .
VALUATION
�s®o, oO ,
BLDG. DEPT.
4r
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.
❑
NO.
NO.
ADDITIONAL INFORMATION
,
•
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
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
PSL Pi t
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
-31 Service
32. Final