0637 (RPL)PERMIT APPLICATION
r. City of La Ouinta • '
Department of Building and Safety
This permit becomes void if work not commenced within 180'days from date of issuance. OR, if work has been suspended or, abandoned fir a, 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 ($100),o,.less. I'certify that 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 is in full force
issued: I shall not employ any person in any manner saasto become subject to the Workers'Comoensation Laws of
and effect.
California.
License Class Lic. Number
Date Applicant
Date" -,Contractor
NOTICE TO.APPLICANT: If, after making this Certificate,oLEzemption, 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
be deemed revoked: '
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following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit
.
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' construct, alter, improve, demolish, or repair anystructure, prior to its issuance, also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFIC-ATION:
• such permit to file a signed statement that.he is licensed pursuant to the provisions of the Contractor's License Law
`❑ f4reby cer*tify that no excavation five (5)'or more -e6t indepth into which a peirson is required to descend',w ill 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, lalsework, or
' therefrom and the basis.for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit •
demolition or dismantling thereof, will be more than hirtysix (36) feethigh. (Chap 3.2, Grp 2, Art 2, Sec341, Title8:
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): �' r
C.. AiCj. '
❑ 1. as owner of the property, or,my,employees with wages as their sole compensation, will do the work, and.the.
❑ 'As owner -builder, 1 wilt not employ anyone to oo 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, add who does such work.himself or
a
ale If, however, the
through his own employees,•provided that such improvements are not intended or offered for sale:,
17 Division of Industrial Safety -Permit No.
building or improverrint is sold within oneyearof completion, theowner-builder will have the burden of provingthat
Date Applicant-'
:.he did not build or improve for the purpose of sale:). r„
-CONSTRUCTION LENDING AGENCY: I hereby affirm flat there is a construction lending agency for the performance
O 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. -3(197, 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 the ' • -
- -
Contractor's License Law.).
Lender's Address
�'❑ I am exempt under -Sec. B. 8 P.C.'(Atlached Certificate).
I certify that I have read this application and state ttat the above information is correct. I agree to comply with all
Date Owner `
city and county ordinances and state laws relating t., building construction, and hereby authorize representatives '
LOT -SZ
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
END ...
' certificate of Workers' Compensation Insurance., or'a.certified,copy thereof (Sec. 3800. Lab: C.).
Signature of Applicant or Agent Date
Policy No. Company..
CERTIFICATE OF COMPLIANCE AND AUTHORIZATIONOF ENTRY: A certify I have read this application and statethat
❑Certified copy is hereby furnished. _ .. : •. .,�%
wft y` '
the information given is eorrectA agree to comply with all state laws and county ordinances relating to buidling.
construction, and authorize a'representative of the: City of La Ouinta.Department of Building and Safety to enter
❑ Certilied is -filed the City Building InspectioroDepartment or Ci Department"
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upon the property for which t have applied for this permit for the purpose otmiiking inspections.
Date ` Applicant'
�i`iC-AN. �E1(Q! 'e1'ty
ADDRESS
CI >Y'/COMMIJNTY/STATE/ZIP'
JOB S6 E ADDRESS/SPACE '
T /T �� Z7.0 W r/� r// 5 i<4 �OitJ /TA
CITY/COMMUNITY/STATE/ZIP
BOK
PAG
PRC
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TWN
RNG
SE
S
TRACT •
L'O-
MOD
SB
TRACT NAME
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME
ADDRESS • .
CITY/COMM UN I TYISSTAATTE/Z I P
70
ARC/ENG FIRM NAME . .
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE N -
-
LICNC M
.
USE OF PERMIT -
�
ZON
FSB
SSB
SSB
'RSB
OFC
ZONE ORD'*
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END ...
.-SIDE,
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPUPRMTr TA T � F
f�cA •J''.S -D�
TOTAL
FEE
BLDG. DEP'VALUATION ��G'r%� ®p•
.
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 E
9
Garage Fire Wall
42
Commercial Hood
10
Fireplace P. L.
❑
43
Final
10A
fireplace T.O.-
❑
NO
ADDITIONAL INFORMATION
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 PiI
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B, Bonding
30 Fixtures
31 Service
32 Final