0614 (RPL)PERMIT APPLICATION- "
_ City of La Ouinta
)I ! ' ` 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 I it a period of- 180 days:
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CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
' LICENSED CONTRACTORS DECLARATION: Thereby 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 of the Business and Professions Code, and my license is in full force ,.
issued, I shall not;employ any person inany manner si, asto become subject tothe Workers'Compensation Laws of
and effect.
California.
License Class Lic. Number
_Date Applicant
�^ Y
' Date ' Contractor•
NOTICE TO APPLICANT: If, after making this Ceroficde of Exemption, you should become subject to the'Workers'..
• ' ' .'
OWNER -BUILDER DECLARATION: I' hr::ereby atfirrn.ihat I am exempt fro the Contractor's License Law for the
Compensation provisions of. the. Labor Code, yowmust forthwith comply with such provisions or this permit shall e'
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 CERTIFICF-TION:
,. such pprmit-to file a signed statement -1 -hat he is licensed pursuant to the provisions of the Contractor's License Law
❑ I hereby'certify that no excavation five 15) or more Pet in depth into which a p - erson is required to desc end, will be •d
(Chapter 9(commencing with section 7000) 01 Division 3 of the Business and Professions Code) or that he is exempt
- made in connection with work authorized by this pernit, 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 for a permit
demolition or dismantling thereof,.will be more than t airty,six (36) feet high. 3.2; Grp 2, Art 2, Sec 341,.Title 9.
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):.
_(Chap
CAC.)
.01. as owner of the property, or my employees with wages.as their sole compensation, will do the work,'and the
0 Asowner+6uilder, I Will`not employ anyone to M 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 pers.n has a permit to do such work from that division:
Law does not apply to an owner ol.property who•builds, or improves thereon, and who does such work himself or
I. .
through hisoWn employees, provided that such improvements are not intended or offered for sale. If. however, the
„ .. 0 Division of.fndustrial Safety Permit No.
building orimprovemntissoldwithinoneyearofcompletion,theowner•builderwillhavetheburdengLprovingthat.
Date Applicant -
he did not build or improve for the purpose of sale.).:z*
CONSTRUCTION LENDING AGENCY: I hereby affirm Oat there is a construction lending agency for the performance.'
❑ 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. 30+7, 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 contractors) licensed. pursuant to the..
SS8
Contractor's License Law.).. ..
Lender's Address
0'1 am exempt'underrSec. B. B.P.C. (Attached Certificate). ,'
I certify.that I have read this application and state that the above, information is correct. I agree to comply with all
Date • • Owner'
city and.county ordinances and,state laws relating tc building construction, and hereby authorize representatives
WORKERS' COMPENSATION OECLARATA: I hereby affirm that I have a certificate of consent to self -insure: or a
of this county to entef upon the above-mentioned property for inspection purposes.
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 AUTHORIZATION OF ENTRY: I certify I have read this application'and state that .
.O Certified copy is hereby furnished. -hv
the information given is correct. I agree to comply viith all state'laws and county. ordinances relating to buidling..
❑ Certilied-copy is filed, with the'City Building Inspection DDepartment or_6City Depa moment...
construction; and authorize a representative of the City of La Ouinta Department of Building.and,Safety to enter '
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// ��� /r !/'/ �f ! I ?/ze :. /' /�T
upon the property for which I have applied for this permit for the purpose of making inspection's. ..
Date �� Applicant .
Signature of Applicant or Agent Date
APPLICANT. NAME (L'I.MI)
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CITY/GOMMI�UNI�Ye/STATE/ZIP����
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CITY/COMMUNIT,Y/STATE/ZIP - -
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RECF_IVE0-
MAR 2 '�G8
TRACT NAME -
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME . • -
ADDRESS -
CITY/COMMUNITY/STATE/ZIP
PHONE f � � /G� �
oNAME
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ARC/ENG FIRM
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 11
LICNC 11 r
USE OF PERMIT _
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SSB
RSB.'
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END.
SIDE
Print Applicant/Agent Name
APPUPRMT DATE
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RECF_IVE0-
MAR 2 '�G8
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TOTAL'
FEE •
641,C%
•
BLDG. DEPT. VALUATION
NO.
OPERATION DATE
INSPECTOR
NO.
s—
OPERATION DATE INSPE ,TOR
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.
❑
OPO'N
ADDITIONAL.IN FORMATION
/ I
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 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
PSL P/I
STREET NAME
26 Power,Pole
27 Conduit
28 Service Entrance
.29 Wiring
29A Grounding Wire V
29B Bonding'
30 Fixtures
31 Service
32 Final