0606 (RPL)--"-,-PERMIT APPLICATION
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City of La Ouinta �. Y
rr 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 fcT 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:' I hereby affirm that I am licensed under provisions -of Chapter'9 ~'..'
the permit is for one.hundred ($100)o. lessll certify that in the performance of,the work -for which this permit is. -
' (commencing with Section- 7000),ofOvision Sof the Business and Professions Code„and my license is in full force
issued, I shall not employ any person inany manner so as to become subject to the Workers: Compensation Laws of
and effect. (� ��
California.
-3
License Class Lic: Number
Date Applicant
'Date Contractory, -'• "�`�r
NOTICE TO APPLICANT: If; after making this Certifica-e of Exemption; you should become subject to the Workers' . .
OWNER -BUILDER DECLARATION:: I hereby affirm that I' am exempt from the Contractor's License Law for the . .
Compensation provisions of the Labor Code, you musl forthwith comply with such provisions or this permit shall
following reason (Sec. 7031.5. Business and Professions Code: Any,city or county which requires a.permit to
. 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;,
such permit to file a signed statement that he is licensed pursuanttothe provisions ofthe Contractor's License Law
❑ 1hereby certifythat noexcavation five (5)orrnorefeetindepth into which ape'sonisrequired todescend. will be-.
(Chapter 9(commencing with section 7000) 01 Division 3 of the Business and Professions Code) orthat he isexempt .
made in connedl04 with work authorizedby this permit, 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 morelhan ttirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341, Title 8,
fiv
subjects the applicant to a civil penalty. of not•more than e hundred dollars ($500.):
C.A.C.) - .
❑ I, as.owner of.the property, or my employees with wages.as their sole compensation, will do the work, and -the
❑ As owner-builder,'l will not employ anyone to do 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 person 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.
• ' . n, . •
through his own employees. provided that such improvements are not intended or offered for sale. If, however, the
O Division ot,lndustrial Safety. Permit. No.
building or improvemnt•is sold within one yearof completion. the owner -builder will have the burden of proving that •-
Date Applicant -
he did_ not build or improve for the purpose of sale.).
%CONSTRUCTION LENDING AGENCY: I hereby affirm INN there is a construct Whinding agency for the performance
: b. 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: 3097, 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'pursuanbto the
Contractor's License Law.). _
Lender's Address
0 1 am exempt under Sec. -B. 8 P.C. (Attached:Certificate).
.: I certify that thave read this application and state th3 the above information is correct. I agree to.comply with all
Date owner
city and county ordinances and state laws relating to 3uilding construction, and hereby authorize representatives ..
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of this county to enter upon the above-mentioned poperty for -inspection purposes. ' • . .
WORKERS' COMPENSATION DECLARATION: I hereby:affirm that I have a certificate of consent to sett -insure, or a
.certificate of Workers' Compensation Insurance • or a certified copy thereof (Sec: 3800. Lab. C.)a. -
Signature of ApplicanLor Agebt Date
Policy No. _ Company..
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION EF ENTRY: Icertify Ihave read this application and :state that :
O Certified,copy is hereby furnished.
the information given is correct. I agree to comply.wth all.state laws and county ordinances relating to buidling
❑ Certified •cdpy is filed with the City Building Inspectioh Department or,CityDepartment. '
construction; and authorize a'representative of the city of La Ouinta Department of Building and Safety, to enter .
Date Applicant
uponlhe property for which-l.have applied for this lermit,for the puipose of making inspections. .. .. '
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Signature of Applicant or Agent Date .
Print Applicant/Agent Name -
AP1wei✓��L F rV _5A4,65 ..
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CI�`MITY/STATEF/ZI�l/ ;
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CIJV/N�OMMPITY/STATE/ZIP
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TRACT NAME
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME ..
ADDRESS
CITY/COMMUNITY/STATE/ZIP .
PHONE .
LICNC e'
ARC/ENG FIRM NAME .
ADDRESS '
CITY/COMMUNITY/STATE/ZIP
PHONE U .
-
LICNC .
USE OF PERMIT -
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SSB
SSB
RSB
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APPL/PRMT nsn-fi-��/JE�,
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BLDG. DEPT.
3
TOTAL
FEE
VALUATION
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.
❑
NON
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)
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