0608 (RPL)APPLICANT N ME (L..r I� ..
ADDRESS .2 .
PERMIT
APPLICATION
/ V•f3
City
of La Ouinta
Department
of Building and Safety
This permit becomes void if work not commenced within 180 days.lrom date of issuance: OR, if work has been suspended or abandoned for a period of 180 days. '
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CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENEiATION INSURANCE: This section need not be completed it '
LICENSED CONTRACTORS DECLARATION:- I hereby.affirm that,) am' licensed under provisions of Chapter 9 .
.. the permit is for one hundred ($100) o, less. I certify tYat in the performance of the work for which this permit is
• (commencing with Section 7000) of Division 3 of the Business and ProfessionS.Co}If my liven a is in lull force
issued, I shall not employ.any person in any manner,so.-s to become subject to the Workers'Compensation Laws of -;
�nd�
and effect. 7 �l Y
California.
_ License Class LicJNumber z / f-- .
Date Applicant
_
• Date . Contractor �C 1�'
NOTICE TO APPLICANT;.If„af.. im king this Certificate of Exemption,. you should become subject to the Workers:.'
OWNER -BUILDER DECLARATION: I hereby affirm. that I'am.exempt.lroin the Contractor's License Law for the
Compensation provisions of: the Labo%gode, you mustforthwith comply with such provisions or this permit shall .
be deemed revoked. '
following. reason (Sec. 7031.5. Business and Professions Code: Any city -or county, which requires a permit to..
ADDRESS
construct, alter,.improve, demolish; or.repair any structure, priorlo.ils issuance, also requires the applicant for
.. DIVISION OE INDUSTRIAL SAFETY PERMIT CERTIFICATION; .. .
• ' such,peirmitio..file a.signed statement.that he is licensed pursuant to the provisions of the Contra,ctor'sLicense.Law.
❑ 1 hereby certify that no-6cavatioti five (5) or more feet iii dioth int6 wfiich a person is required to descend, will be
(Chapter 9(commencing with section 7000) of Division 301 the Business and Professions Code) orthat he is exempt..
made in connection v`rillf-work authorized by this permit, and that no building structure, scaffolding, lalsework, or
therefrom and the basis for the alleged exemption. Any.violation of Section 7031.5 by any applicant fora permit
demolition or dismantling thereof, will'be more than thirty-six (36) feet high. (Chap 3.2, Grp 2:Art 2, Sec341,Title 8,:
subjects the applicant to a civil penalty of not more than five fiundred.dollars ($500.):
C.A.C.)"- ^-"M1''`• ' '
❑.l. as owner of the property,,or my employees with wages as their sole compensation, will do the work: and the
❑'As owner -builder; I will not einploy'anyone to do work:whichwould 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 persor 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
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.� through his own employees, provided that such improvements are not intended or offered for sale. If, however. the '
�-Division of Industrial Safety Permit No.
•.. building o[jgiprovemnt.is sold within one year of 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 tha- there is a construction lending agency for the performance
.0 1, as owner of the property, am•exculsively.contracting with licensed contractors to construct the project (Sec:.
' .of the work for which this permil•is issued (Sec. 309? -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. 8 P.C. (Attached Certificate)..
I certify that I have read this -application and state thatthe above information, is correct..) agree to comply with all
s
Date Owner,' ° `
-.city and county ordinances and state laws relating to hlilding construction, and hereby authorize representatives.
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of this county to enter upon the above-mentioned proerty for inspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that.I haven certificate of con sent, set l-insure„ora
'
' certificate of Workers! Compensation Insurance , or axertified copycThereof (Seci 3800; Lab. C.).. `r .
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
p Certified copy is hereby furnished.
the information given is correct. I agree to comply with`all state laws and county ordinances relating to buidling .
❑ Certified copy is'filed with the City Building Inspection Department or.City Departmeni,;
- construction, and authorize a' representative of,the.0 ly of La Ouinta Departmentot Building and.Safety to enter ;
upon tfie property.lor which I have applied for this p.rmitfor the purpose of making inspections.
Date Applicant
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Signature of Applicant or Agent Date,
APPLICANT N ME (L..r I� ..
ADDRESS .2 .
CIT COMMUNITY/STI�.T.E/ .•
2_C�q:
JOB SITEi ODrjESS�S/�PJ/4E �y
57-
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TRACT NAME -
OWNER NAME (L. F. MI) - .- ...
CONTRACTOR -FIRM NAME ,. .. ...
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 0
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ARC/ENG FIRM NAME -
ADDRESS
CITY/COMMUNITY/STATE/ZIP ..
PHONE N
I.LICNC
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USE OF PERMIT
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.SIDE -_
Print Applicant/Agent Name
APPL/PRMT
p?a asp/ Si°r4
216- -SPA
BLDG. DEPT.
TFEE r Qom"
VALUATION S OO'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
3 1 I Y
��12A
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SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
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
29B Bonding
30 Fixtures
31 Service
32 Final