0604 (RPL)APPLICAIILTPN^M/dj,%,LMI� 6%J.>
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 abandonec for a period of 180 days.
c.
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if .
LICENSED CONTRACTORS 'DECLARATION: I hereby affirm that t am licensed under provisions ..of 'Chapter 9' " ..
the permit isJor one hundred ($100) o, Jess. I certiy that in the performance of the work for which: this permit is
(commencing with Section'7000) of Division 3 of the Business and Professions.Code, andmy m ull force • ...
.. ' . issued; I shall not employ any person inany mannerso asto become subject to the Workers' Compensation Laws of
/license'is
and effect.�Q 7
California. .
License Class - Lic�iNumber
Date Applicant
//
Date • Contractor IZ ' J '✓r }^'-n 1
NOTICE TO APPLICANT: If„after making thisCertifi�ale of Exemption; you should become subject to the Workers'. '
- OWNER -BUILDER' DECLARATION: I hereby affirm that f am exempt from the Contractor's. License Law for•the _
'fallowing
Compensation provisions of the Labor Coderyou.rrust forthwith comply with such, provisions or thispermitshall
be deemed revoked,
reason'(Sec. 7031.5. Business and Professions Code: Any city.or'county which requires.a permit to
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' construct, alter, improve; demolish, or repair any structure, prior to its issuance, also requiresthe applicant for
DIVISION,OF INDUSTRIAL SAFETY.PERMIT CERTIFII:ATION:
•.such permit to file a signed statemenithatheislicensedpursuanttothe provisions ofthe ContracwsLicense Law, •
0'I hereby cirtify that do excavation five (5) or rhore feet in depth into which a person is required to descend. will be '
(Chapter 9.(commencing.with section 7000) of Division 3 of the Business and Professions Code) or,thathe is exempt;
made in connection with work authorized by this pe -mit, and that no building structure, scaffolding, falsework; or ,+
therefrom. and,lhe basis for the alleged exemption. Any violation of Section 7031.5 by. any applicant for a permit' ......
:demolition or dismantling.thereof will be more thanthirty-six (38) feet high. (Chap.3.2, Grp 2, Art 2. Sec341, TitleB,-
subjects the applicant to a civil penalty of not more than live hundred dollars (5500.):
CAC) ' G %l li _
-13 I. as owner of the property, or my employees with.wages,as theirsole compensation, will.do the work,.and the
.0 As owner -builder, I will not employ anyone to Jo 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 per on 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
USE OF PERMIT
through his own employees: provided that such improvements are not intended or offered for. sale. If, however. the , -
: O Division of Industrial Safety Permit No,'
.. .
-. building orimprovervrtissold within one.yearofcompletion. the owner -builder willhavetheburden.ofprovingthat•-
Date- ^- 'Applicant. -
he did not build or improve for the purposI.e of sale:), ., r ( ,
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
O I, as owner'of the property, am exculsively contracting with licensed contractors to construct the project (Sec: -.. ^.
• •of the work for-whichthis permit is issued (Sec. 31f97, 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 .
Contractor's License Law.).
Lender's Address—
0 1 am exempt under Sec.' B. & P.C,(Attached Certificate):
('certify that I have read this application and state flat the above information is correct. I agree to comply with all,
ca
Date Owner' '
city and county ordinances and state laws relating m building construction, and hereby authorize representatives
'county
`
of this to•enter upon the above-mentioned Iroperty'for inspection purposes.
• WORKERS' COMPENSATION DECLARATION: .1 hereby affirm that I have a certificate of consent to self -insure, ora ..
- .. . •• -
'certificate of Workers' Compensation Insurance ..or a;certified�copy thereof, ;(Sec.,3800. Lab. Q.
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.
ihe,information given is correct. I agree to comply:with all state laws and county ordinances.relating to buidling
' ❑ Certified topy'is filed with the City Building Inspection Departnierit'orCity Department.
construction; and authorize a'representative of therCityof La Ouinta Department of Building and.Safety to enter
o
•upon
the property for which.) have applied for this,permit for the purpose of making inspections. ,
Date Applicant
”
Signature of Applicant or Agent Date
Print Applicant/Agent Name ^
APPLICAIILTPN^M/dj,%,LMI� 6%J.>
CA L Y10yIST;gZ2P 5, 7
JOB SIT AD�RESS/S(,I�JC�'
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TRACT NAME
OWNER NAME (L, F. MI) - ••
CONTRACTOR -FIRM NAME • ' + -< '
ADDRESS ..
CITY/COMMUNITY/STATE/ZIP
PHONE • -
LICNCM
ARC/ENG FIRM NAME ,
ADDRESS - -
CITY/COMMUNITY/STATE/ZIP •' -
PHONE •
..
LICNC N
USE OF PERMIT
BL..
ZON .
'-
FSB.
'SSB`
SSB
RSB
OFC
ZONE ORD rl..• ; -,
• . LOT SZ ; -
END.
SIDE.
BLDG. DEPT.. VALUATION''1���•DU
+
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
Fireplace T.O.
❑
OP'NO. ADDITIONAL 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)
12CT 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
REAR OF PROPERTY
PSL
STREET NAME
LINE.
P/1
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final