0634 (RPL)PERMIT APPLICATION "
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 fora period of 180 days
. ^ - . I • . ' •.. 1 ., .
CERTIFICATE OF -EXEMPTION FROM WORKERS' COMF_NSATION 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).0, less. I certify that in the performance of the work for which this permit is
.(commencing with Section 9000) of Division 3.of the Business and Professions Code, and mylicense is in full force • .
issued, I shall not employ anyperson in any manner so as to become subject to the Workers'Compensation Laws of
and effect.
California.
License Class Lic. Number
Date Applicant
u Date' Contractor
NOTICE TO APPLICANT: If, after making this Cerlificnte of Exemption, you should, become subject to the Workers'
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License law'lor. the
Compensation provisions of the Labor Code, you mast forthwith comply with such provisions or this -permit shall
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 permil.to file a sigDed statement that he is licens.ed pursuant to the provisions of the Contractor's License Law
0dherebycertifythatnoexcavationfive(5)ormore=eetindepthintowhichapersonisrequiredtodescend,willbe
(Chapter 9 (commencing.with section 7000) of Division 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.*Usework, or -
Aherelrom and the basis for the alleged. exemption. Any violation.of Section 7031.5 by any applicant for a permit
' demolition o(dismantling-thereof, will be more than fhirly-six,(36) feet high'. (Chap 3.2,'Grp 2, Art 2, Sec341, Title B. '
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): dr - ..
C:A.C.) - - » ^
.0 I. as owner ol.the property, or my employees with wages as their sole compensation, will Bothe work, and they
As owner -builder, I will not employ anyone to • o 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.lhat division.. -
Law does not apply to an owner of properly who builds, or improves'thereon, and who does such work.himself or- .
0 Division 'of Industrial Safety.Peimit No.
' through his own employees: provided that such improvements are not intended or offered for sale. If, however, the
r
building orimprovemntissotdwithin one year opcompletion, the owner.builder will have the burden of proving that
'Dat e Applicant
he did not. build or improve for the purpose o. sale.). -, �. j
CONST.RUCT,iON LENDING AGENCY: I hereby affirm Oat 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•woik for -which this•permit is issued (Sect 307,.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 to the , .
• - - -
Coniractor's.License Law.).
Lender's Address
' Cl I am exempt under Sec. AA 8 P.C. (Attached Certificate).
I certify that I have.read this application and state It -at the above information is correct. I,agree to comply with all
Date ' Owner r
city and county ordinances and state laws relating t•• building construction, and hereby authorize representatives
of this county to enter Upon the-above•mentioned property for'inspectiom purposes.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of. consent to self -insure, or a.
certificate of Workers' Compensation Insurance • ora certified copy thereof (Sec. 3800. Lab. C.). , •^ 4.,.
Signature of Applicant or Agent. Date' '
Policy No; Company.
CERTIFICATE OF COMPLIANCE AND AUTHORIZATIONIOF ENTRY: I certify I have read this application and state that -
O, Certified copy is hereby furnished. � � -• � I - � ,.-
�D(Partmenl
the information given is correct. I agree to comply vith all state laws and county ordinances relating to buidling
❑ Certified copy is*(iled`with the City Building Inspection De tment or City `=
construction, and.authorize a'representative of theCity of La Ouinta Department of Building and Safety to enter
upon the property for which I have applied foi Ihisipermit for the,purpose of making inspections.
Date Applicant
Signature of Applicant or Agent S. Dale .
Print Applicant/Agent Name
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OWNER NAME (L. F. Mn .. •• ,r
CONTRACTOR -FIRM NAME - • . -,
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE a' / //�
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LIL NC
ARC/ENG FIRM NAME[%
ADDRESS ..
CITY/COMMUNITY/STATE/ZIP - ..
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LICNC It
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USE OF PERMIT -
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END
SIDE ,
.APPUPRMT n�.�7�.�� ATE n
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1
TOTAL
FEE
VALUATION ^.2 � 00, .0
BLDG. DEPT.
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
fireplace T. 0.
❑
OP'10A
NO. ADDITIONAL INFORMATION
NO.
, I
yI�
,
'
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12, Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick al
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
P/L PiI
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
STREET NAME