0633 (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 far a period of 180 days
' . . , , . - ' -
"t'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. :hat in the performance of the work for which this permit is
(commencing with -Section 7000) -of Division Sof the Business and Professions Code, and my license -is in full force.
'issued, ) shall not employ any.person in any manners- as to become'subject to the Workers' Compensation Laws of -
and effect.
California.
License Class Lic. Number
Date Applicant.
Date Contractor '-
NOTICE TO.AP.PLICANT.::If, alter making this Certifica a of Exemption, you should become subject to the Workers' -
OWNER-BUILDER'DECLARATION: I hereby affirm that l -am exempt' from the Contractor's License Law for the
Compensation provisions of the'Labor Code, you mu -)forthwith comply with such provisions or this permit shall
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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 isseance, 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 heieby certify that no excavatio6 live j5) or mori f!et in depth into which a person is required to descend. will be
(Chapter 9 (commencing with section 7001) of Division 3.of the Business and Professions Code)or.thathe is exempt. -
made in connectiorrwith work authorized by this peinit, and that no building structure; scaffolding, falsework, or-,
therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by. any applicant fora permit
."demolition oF-dismantling thereof, will be more than.tt irty-six (36) feet high. (Chap 3.2, Grp 2, AA 2; Sec 341, Title 8,
'subjects- the, applicant to a civil penalty of not more than five hundred dollars ($500.):
' ' CAC.) •c
: 0 1. as owner_of the property, or my employees with wages as their sole compensation, will do the work, and the ,
0 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. 7044, Business and Professions Code: The Contractor's License-
Industrial Safety,as noted above, unless such perscn 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
ADDRESS -
: through his own employees, provided that such improvements arenot intended or offered for sale. If, however, thea-
- 0 Division of Industrial Safety Permit No.
buildingor improvemnt is sold within one year of completion,.the owner -builder will have the burden of proving that
Date Applicant
he did: not build or,improve.for. the purpose of sale.).; , .
CONSTRUCTION LENDING AGENCY, I hereby affirm that there is a construction lending agency for the performance '
0 I: as owner of the property, am exculsively contracting with licensed contractors to'constructthe project,(Sec:
of the work for which.this permit is issued (Sec: 309;:Civ. C.).4, 2.c
7044. Business and Professions Code: The Contractor's License Law does not apply to an.owner of property who
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Lender's Name
builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the
SS8
Contractor's. License Law.).....
Lender's Address
' . 0 I -am exempt undeFSec. B: 8 P.C: (Attached Certificate). -
I certify that+have read this application,and state tfia9he above information -is correct. I agree to comply with all
Date Owner sr
city and county ordinances and state laws relating tobuilding construction, and hereby authorize representatives
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
` certificate of Workers' Compensation Insurance , ora certifiedcopy, thereof (Sec.. 3800. Lab. C.). •
Signature of Applicant or Agent Date
Policy No. Company _
CERTIFICATE OF COMPLIANCE ANDAUTHORIZATION -1F ENTRY: I certify I have read this application and state that
rnished. - /
0 Certified cophereby furnished.
a the information given is correct. I agree totcomply wah 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
0 Certified cgDY Isdited wittvth City Building Inspection•Depar"tme�1'or City'- - �bepartmenti
-
(ecu . rr7 s
Date f �i'
upon the property for which I have applied for this lermit for the purpose of making inspections.
Applicant
Signature of Applicant or Agent Date
APPLICANT NA E J'MI)� n f-
70Yfltl�is—'/ Iri S
CITY/CO�MUUNITYSTAT ZIP
JOB 5170 -,- 3 7 R W� / 1Vyjr, F•r aA/ 17 A
CITY/CO UNITY/STATE/ZIP . , . ' ' "•
At
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P`/A"D
PRC
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L.70 tr[/
MGD
SB
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TRACT NAME
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME
ADDRESS .. .
CITY/COMMUNITY/STATE/ZIP
PNO-;NE, y�i � •,� /�jD 61
LICNCL%/
ARC/ENG FIRM NAME0
ADDRESS -
CITY/COMMUNITY/STATE/ZIP '
PHONE 0 '
LICNC 8
-
USE OF PERMIT -
81.
ZON '
FS8'
SS8
SSB
RS8
OFC.
ZONE ORD N
LOT SZ -
END.
SIDE
Print Applicant/Agent Name
'APPL/PRMT
/T To /lel S7,4`4 15
TOTAL-
FEE
VALUATION
BLDG. DEPT.
NO.
OPERATION DATE
INSPECTOR
NO. OPERATION DATE
h SPEgTOR
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.
❑
NON ADDITIONAL INFORMATION
p
K/�
T ZL- v� y
-
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
P/L
STREET NAME
PyI
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
296 Bonding
30 Fixtures
31 Service
32 Final