0630 (RPL)+ _ PERMIT APPLICATION
a City of La
Ouinta •-
Department of Building and Safety i
CITY-/COtAMUNiijY/STATE/ZIP
BOK.
", - • 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.- z
PRC C.
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..CERTIFICATE OF EXEMPTION FROM WORKERS' COMP 14SATION INSURANCE: This seclion,need not be completed if
LICENSED CONTRACTORS DECLARATION:'l hereby affirm that'I am licensed underprovisions, of Chapter 9 ' . .
+!the permit is for one. hundred, ($100)0, less. I certify :hat.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,.[ shall not employ any,person in any manners+ Asia become subject tothe Workers`Compensation Laws of. • . .
and effect.
California. _
License.Class. ' Lic. Number -
Date Applicant,
'c Date • : Contractor
•NOTICE.TO APPLICANT: If, after making.this Certificate of Exemption„you should hecomesubject lo.the Workers'
OWNER -BUILDER DECLARATION: I hereby affirm that am exempt irom4he Contractor'sLicense Lawlor the.
Compensation•provisions of the Labor.Code, you must 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. -
t
' 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 pursuanitothe provisions of the Contractor's License Law..
",❑.I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, Will be
._,(Chapter9,(cbmmencingwith.section,7000)ofDivision3oftheBusinessandProfessionsCode)orthatheisexempt,.,'.
'
made -in cbnnectiori with'work authorized by.this perinit and thatno building structure, scaffolding.. falsework. or
therefrom and the basis for the alleged exemption. -Any violation of Section 7031.5 byany applicant for ape rmit
demolition or dismantling thereof; will be more than t5irty-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 (SWO.):
C.A.C:)
❑ Las owner of the property, or my employees with wages.as their sole compensation, will do the work; and,lhe ' .
p As.owner-builder: Twill not employ anyone to db work which would require a permit from the Division of <
.'structure isnot intended or.offered for. sale (Sec. 7044, Business and' Professions Code: The Contractor's License ., -
Industrial Safety, as.noted above, -unless such pers6 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 doessuch work himself or
through his own employees. provided that such improvements are not intended or offered for sale. If, however, the - .,.
0 Division of lndustnalSafety Permit No.
building orimprovemntissold within one year ofcompletion; the.owner-builder will have the burden of provingthat ,
Date Applicant '
he did.notbuild or improve for the purpose of sale.).
'CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance .
..❑ l: 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. 30!7, Civ. C.) ,.
7044. Business and Professions Code: The Contractor's License Law does'not,applyto 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
,,.• O I am exemphunder Sec. B: 8 P.C. (Attached Certificate).,, .'..
.I certify that l have read this application and state th d•the above information is correct,) agree to comply with all
Date Dwner '� w re
city,and county ordinances and state laws relating lc building construction, and hereby authorize representatives
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I havea certilicatenfconsent to self -insure, ora.'.
of this county to enter upon the'above•mentioned p-operty tar inspection purposes.
certificate of Workers' Compensation Insurance, or a certified copy thereof:(Sec,38M. Lab. C:).. ; rf'
Signature'of Applicant or Agent ' - Date
Policy No. _ Company
CERTIFICATE OF COMPLIANCE'AND AUTHORIZATION IF ENTRY: I certify I have read'this application and state that
• ❑ Certified copyAisher, by furnished.. ii
the information given is correct. I agree to comply with all state laws and;county ordinances relating to buidling.... -
' ❑ Certified copy' fledswith'�le City Building InspectioyDepart ant o ,City L— Department:,
' % (
construction; and authorize a'representative of the ;ity of La Ouinta Department of, Building and Safety to enter
upon the property for which I have applied for This oermit for the purpose. of making inspections.
Date Applicant t l
_
Signature of Applicant or Agent • Date `
T
Print Applicant/Agent Name
APPLICANT NAME. (L �Ffkb)
AP,PL/PRMT fl S3.0 3/DbAT _'�
VALUATION
BLDG: DEPT.
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TRACT NAME - •• '
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE'll
-ARC/ENG FIRM NAME ..•
ADDRESS - -- -
CITY/COMMUNITY/STATE/ZIP
PHONE M
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USE OF PERMIT
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APPLICANT NAME. (L �Ffkb)
AP,PL/PRMT fl S3.0 3/DbAT _'�
VALUATION
BLDG: DEPT.
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NO.
OPERATION DATE INSPECTOR
NO. OPERATION DATE j IN,P° CTOR
o
BUILDING APPROVALS
I 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.
❑
NOADDITIONAL 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 1 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:
r{. 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