0500 (RPL)PERMIT APPLICATION r
City of La Ouinta
Department of Building and Safety
This permit becomes void it work not commenced' within 180 days from date of issuance. -OR, if work -has been.suspended or abandoned -or a period of 180,days.
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ADDRESS
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CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not De'completed if"
LICENSED 'CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 • • .
She permit is -for one hundred ($100) o. less. I certify -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, and my license is.in full force :.. ,
= issued; I shall not employ any person inany manner E) as to become subject to the Workers: Compensation Laws of
and effect. 41&'l
California:
License Class Lic. Number' I r r
Date Applicant _
• s'Date Contractor �� ' `� - lt° yl� F' `"►
NOTICE TO APPLICANT: If,;after rtraking this Certific rte ol.Exemption jou 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 mist forthwith 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 .: ,
construct, alter, improve; demolish, or repair any structure; prior -to its issuance, also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
suchpermittofileasignedstatementthatheislicensedpursuanttotheprovisionsoftheContractor'sLicenseLaw❑
Iherebycertily4hatnoexcavation live (5)ormoie eetindepth into which aperson isrequired to'descend,will be -
(Chapter 9 (commencing with section 7000).of Division 3 of the Business and Professions Code) orthat heis exempt
•made•iri connection with work authorized by this per -nit, 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 lora permit
demolition or dismantling thereol,'will be more than 'llirtysiz-(36)'feet high. (Chap 3.2, Grp 2, Art 2, Sec341;Title8;
subjects the -applicant to a civil penalty of not more than five hundred dollars ($500.):
C.A.C.) .r 'T' . , '
O I, as owner of the property, or my employees•with wages, as their sole compensation, will do the work, and the ..
D As owner-buildei(h willnot employ anyone, to -0 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 petE)n hasa 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 . -
'through
. • •
D Divisi6n. of Industrial.Safety P,ermit:No.
his own employees. provided that such improvements are not intended or.oftered for sale. If, however, the '
building or improvernnt is sold within one year of completion. the owner-buil.der.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 t tat there is a construction lending agency for the performance
' D I, as owner of the property, am exculsively contracting with licensed contractors to.construct.theproject (Sec..
of the work• for which this permit is issued (Sec. 3®7, Civ. Q.
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): -,.i
;- I certify that I have read this application and state ti at the above information is correct. I agree to complywith all;..,':
Date` OwneY ws
city and county ordinances and state laws relating b building construction, and hereby authorize representatives
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of this county to enter upon the above=mentioned 1roperty for inspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby affirm than have a certificate of consent to.seff-insure, or a,
'
certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. C!): •L: °
Signature of Applicant or Agent 7.Date "
Poli%No. Company
CERTIFICATE OF COMPLIANCEAND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
D Certified copy is hereby furnished.
the information given is correct. I agree to comply with all state laws and county. ordinances relating -to buidling.
' D.CeAified copy is'Iiled with the City Building Inspection Department'or City Department..
,construction, and authorize a *representative of the City of La Ouinta Department o1;Building and Safety -to enter'
'
Applicant
upon the property for which I have applied for this_ permit for the purpose of making. inspections ..... .' . .
Date
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPLICANT-T�+ 7 M�ITOL/�//
ADDRESS
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CITU/CO
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J%!/ E � R ACE qU,L U/_57,4 1-30W1774'
CITY,/COMMUNI.Y/STATE/ZIP - .. • .
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AND
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TRACT NAME -
OWNER NAME (L. F. MI) ,
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE�•� /" '0/11/1
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ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP .. •r -
PHONE 0
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USE OF PERMIT
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`--'END
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APPUPRMT
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^'s TOTAL... • .
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- VALUATION. -
BLDG. DEPT.
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.
❑
OWN
ADDITIONAL INFORMATION
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SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
126 Ceiling (Batts)
12C Ceiling (Blown)
14 1 Final '• ++
PLUMBING APPROVALS
1,5 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
PJL P1
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Finat