0605 (RPL)PERMIT APPLICATION
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-y{',.,=;,,-�-',•r-->'� 'City of La Ouinta - ' • .. � ,
Department of
Building and Safety. ; ;,' •- .
° `- • ` .:.This permit.becomes void if work not commenced within .180 days from date'of issuanceAR, if work has been suspended or abandonec for.a period of 180 days. =
' - ' — - • •
CERTIFICATE OF -EXEMPTION FROM WORKERS "-COWENSATION INSURANCE: This section neednot be completed if
LICENSED CONTRACTORS DECLARATION:'l.herebyaffirm that I am' licensed under provisions of Chapter- 9
`.the permit is for one hundred.($100) o, less. I certi-y that in the performance of the work for -which this permit is
(commencing with Section7000).of Division 3of the Business and Professions Co e7, and-my,li/cense is in.full force ..
,
and effect.
_ issued, I shall not employ any person in anymannecso as to become subject to the Workers' Compensation Laws of
California.
" - .
RNG
License Class ' Lic. Number
' /r
.� .Date -' Applicam '
•-Date,- '- ' Contractor • •
'- OWNERrBUILDER DECLARATION: I herebyeaffirm that I am. exempt from the Comiactor's' License Law'for the'
NOTICE TO APPLICANT: If, atter making this Certifi:ate.of Exemption, you should become subject to the Workers
Compensation provisions of the Labor Code,you must forthwith comply with such provisions 'orthis permit shall c-
- r -
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 CERTIFICATION: ,. /•,''., '' ,. +• Y :�;.
.such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractors License Law;
01 Wretiycertify that 66excavation five (5)or.'mor^feet in depth into whichapersonisrequired todescend,will be,
(Chapter 9 (commencing'with section 760b). of Division 3 at the Business and Professions Code) or that he is exempt
trade in connection with vwork authorized 6y this p, imit, ana that no building structure, scaffolding, falsework, or ••
,;therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by anyapplicantfor a permit . <
• . ': 'demolition orbismantling'thereol, will be more tharethirty-six (36) feet high. (Chap 3:2, Grp Z Art 2, Sec 341:•Title B. ' -it
:1'subjectsthe'applioant to a civil penalty of'not more than five hundred dollars ($500.):
C.A.C.) sem: 1
-O. I, as owner of the property. or myemployees.withwagesas their sole compensation, will do the work,.andAhe "
='- El. As owner -builder,- I will not employ anyone t0 do work which' would require a permit from the Division.of -
structure is not intended or offeredforsale (Sec. 7044, Business and Professions Code: The Contractor's;License ..
-,, Industrial Safety, as noted -above, unless such peaon has a permit to do such work from that division.
.' Lawdoes not apply to an owner of property who builds, or improves thereon, and who does such work himself or °•?
.. �•' =.. : ' ' • - i' - " •,'
through his ownemployees, provided that'such'improvements are not intended oi.offered for -sale. If, however; the ' . "
O Division of.Industrial Safety Permit No.
."building or improvemnt,is sold within onie.yearof completion, the owner -builder will have the burden of proving that
Date.- Applicam'' '
he did not. build or improve for Ahe purpose of,sale.).. "'•I•: • .
CONSTRUCTION LENDING AGENCY::Thereby 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 which'this permit is issued' (Sec: 3D97, Civ. C.). _ F
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) licensedcpursuant to the,
RS8 _
Contractor's License_Law.)...Lender's
Address
-'.O I am exempt under Sec., B. 8. P.C: (Attached Certificate).., `-
.I certify than have read this application and state :hat the above information is'correcI I agree to comply with all.
Date' Owner 0
• ` city and county ordinances and state laws relating to building construction, and hereby authorize. representatives'
'
of this county to enter upon the'ab6e-mentioned,property for inspection purposes.
• WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to sell -insure, ora . '
... .. • -
'• certificate of Workers"Compensation Insurance ;'or a certified copy thereof (Sec. 3800. Lab. C.)r
n r
Signature of Applicant o Agent Date r'
.. Policy No Copan
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read thisapplicatiorfnd state that
O Certified copy is hereby furnished.
the information given is correct. I agree to comply -with all state laws and county ordinances relating to buidling
O Certified copy is filed with the City, Building`Inspection Depart inert. or'City Department:
const ruction,and authorize a'representative of Ito City of LaOuinta Department of Building and Safety to enter ..,.ti
.upon'the property for'which I have applied for th-s'permit for the purpose of making inspections ,
Date Applicant
Signature of Applicant or Agent Date
;i
Print Applicant/Agent Name
APPLICANT 14A6iI %LL•/
ADD
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-JOB SIT-ADDRESS/SPAS)E'
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TRACT NAME -"
OWNER NAME (L. F. MI(.
CONTRACTOR -FIRM NAME i• .: '".;.': -:-
ADDRESS r - - • - ,
CITY/COMMUNITY/STATE/ZIP
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PHONE II - t
LICNC II
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ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP ... -• '
PHONE a
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LICNC N -
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USE OF PERMIT - -
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APPL/PRMT • + I\TEa J0 q
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- • VALUATION -2 5D v .�
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i - BLDG. DEPT.'
- • VALUATION -2 5D v .�
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. ❑
NOADDITIONAL INFORMATION
% _
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick al
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 LINE
P/L
STREET NAME
P/L
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final