0632 (RPL);APPLICANT NAMEJL— F
4.
Alt -
PERMIT APPLICATION
City of
La Quinta
Department of Building and Safety
� PAG
PRC
-This permit becomes -void-if work not commenced within 180 days from date.ol. issuance, OR, if work has been suspended of abandoned fc�- a period of.180 days.
CERTIFICATE -OF EXEMPTION FROM WORKERS'COMPEPSATION INSURANCE: This section need not be completed it
LICENSED CONTRACTORS DECLARATION: I hereby affirm IhaI.I am licensed under provisions of. Chapter 9 -
the .permit is,for one hundred ($100) o, less. I;certity toat-in the performance of the work for which this, permit is t
(commencing with Section 7000) of Division 3 of the Business. and Professions Code; and my license is in full force
tissued, I shall not employ.any person in any manner. SO as to becomesubjectto the.Workers' Compensation Laws of -
and effect. I t
California.
License Class Lic. Number -
Date Applicant,
Date Contractor -
NOTICE.TO APPLICANT: If, after makingthis CertificaLof Exemption, you should become subject to the Workers',
e4t fr6m't6e Contractor's Licen Law
• OWNER -BUILDER DECLARATION: I hereby affirm That I am ex se,
Compensation provisions:of the Labor Code, you mus': forthwith comply with such provisions or this permit shall - • a
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 CERTIFICA.-IDN:
such permit to file a signed statement.thathe is licensed pursuant to the provisions of the Contractor's License Law
of hereby certify that no excavation five (5) or morefet in depthiritc, which a person is required Iddescend,will be'
(Chapter 9(commencing with section 7000) of -Division 3 of.the Business and ProfessionsCode)orjlhat he is exempt
made in connection with,work authorized by ihis p6rait, and that no building structure, scaffolding, falsework, or 0
therefrom and the basis for the alleged exemption. Any ,violation of.Sec - tion 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 Z Art 2, Sec3411. Titlefl,
subjects the applicant to a civil penalty of not more than five hundred dollars.($500.):jz�'�,�.�,
1. a owner o do the work,-ar�il the
05 1 the property, or miremployees with.wages. as1heir. sole compensation, will
0 As' owndr-builder.-I. will not employ anytine10 dc work which, would4equirei 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 perso i has a permit to - do -such -work from that division.
• Law does not apply to an owner of property who builds. or improves thereon. a nd who does such work himself or
ZON
,
through his own employees, provided that such improvements are not intended or offered for sale: If, however, the
0 Division o*f Industrial Safety-Permit.No.,
building or improvemni is sold within one year of completion, the owner -builder will have the burden of proving that
.
Date Applicant -
Applicant --Lr.
did not build or.improve for the purpose of sale.). -
. !.. .. . I . �', - I . . - . . . .•... .:, •, ; . . . .
CONSTRUCTION LENDING AGENCY' VAerebyaffirm that there is a construction lending agency for the perf�rmance, .
as owner of theproperty, am exculsively contracting with licensed contractors to construct the project (Sec:
of the work for which. this permit is issued (Sec.. 309L. Civ. C.).
7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
Lend6r's Name
',builds or improves thereon. and who contracts for -such projects with'a conlractor(s),licensed pursuant to the
.� . . .1 . .
Coniractor's License Law.). . . 1. . . . .': . . . . I . . . . , ,
Lender 's Address . . 1 .
-�O I:am exempt under. Sec., B. & P.C. (Attached Certificate).
I�cerlify that I have read this application and state thac the above information is correct. I agree to comply with all
Dale Owner.
-city and county ordinances and state laws relating lo.Duilding 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.1 have a certificate of consent to self -insure, ora
certificate of'Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. C.)-, .
Signature of ApolicanforAgent
%Policy No. - Company -1
CERTIFICATE OF'COMPLIANCE AND AUTHORIZATION IF ENTRY�. I certify I have read this application and state that
• Certified copyis)hby furnished.- ',=TA';.—It:
1he information given is correct; I agree to comply wrch all state laws and county ordinances relating to buidling
'representative the City La Ouinta Department Building Safety
• Certiiied copyrishilederewith the City Building Inspection,I) rt enc orClty -'.Department.
construction, and authorize a of of of and to.enter
upon the 'propelirty for-wfiich I have applied for this permit for the purpose of making inspections.
Date Applicant 'r
.4 ican
. .�.
e. J
Signature of Applicant or Agent Date
Print Applicant /Agent Name
;APPLICANT NAMEJL— F
4.
APDRES�,
CITT/GONG NITV TADZIP-
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J 0 B ySIT EeADDRESS/SP
7A7 t741e7, �",4 130.4V17,4
Cf/qPMMUNITY/STATE/ZIP
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FIND
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qTRACTqyg
.5 LOT
MOD'
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TRACT NAME
OWNER NAME (L. F. MI)
-CONTRACTOR-FIRM NAME'
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE'S
LICNC
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 0
LICNC 4
USE OF PERMIT
81.�
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END 'I
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APPUPRIAT
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TO*AL-
FEE
BLDG.DER,T.
'VALUATION
J. ., Ali
,
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
f=ireplace T.O.
❑
NON ADDITIONAL INFORMATION
�iv r�� /
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[
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 P/I
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final