0499 (RPL)PERMIT APPLICATION "
City of
La Ouinta
Department of Building and Safety
This permit becomes void if.work not commenced. within180 days from date of
issuance:'ORJf'work has been suspended or abandonec -for a period of 180 -days.
PAG
CERTIFICATE OF EXEMPTION FROM WORKERS' CONDENSATION INSURANCE: This section need not be completed if
LICENSED CONTRACTORS DECLARATION: I hereby affirm Ghat I. am licensed under provisions of Chapter, 9
the permit is for one hundred ($100) o. less. I certi-y that in.the performanceof the work for which this permit is-
s•-(commencing
(commencingwith Section 7000) of Division 3 of the Business and Professions Code, and li�nse�s•in full force '. ••
issued, I shall not employ any person in any mannerso as to become subject to the Workers'Compensation Laws of,. • .
and elfect. i�`Gr', (� /9'
California.
License Class Lic. Number
Date Applicant.
" Date' Contractor •" y
-NOTICE TD -APPLICANT: lf,�after making this Certificate of Exemption; you should become subject to the Workers'
" OWNER -BUILDER DECLARATION: L hereby affirm that'I am exempt Irom the Contractor's License Law for the
Compensation provisions:of,the Labor Code, you must 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 CERTIFI;ATION:
such permit to.fileasignedstatementthat heislicensedpursuant tothe provisions ofthe Contractor's License Law . ..
O'1herebycertify ihatnoexcavation fk(5)ormonfeet indepth into which aperson isrequired todescend, will be: '
,. • (Chapter.9(commencing with section 7000) of Division 3 of the Business and Professions Code)or that he is exempt .
made'in'connection with work authorized by this grinit, and that no building structure, scaffolding, falsework, or
therefrom and the.basis for ihe.alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
demolition or dismantling thereof; will be more thart6irty-six (36)deet high. (Chap 3.2, Grp 2. Art 2,'Sec341, Titlelf • '
subjects the applicant to a civil penalty of not-more'than five hundred dollars (5500.):
C.A!C:)'
-O I, as owner of the property: or my employees with.wages as their sole compensation, will do the work, and the
O As owner -builder, I'will'not employ anyone to do work which would require a permit'fiom 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
BL
• through his own employees, provided'that such improvements are not intended or offered for sale. If, however, the
; O Division of,lndustrial Safety Permit No.
building orimprovemntissoldwithin one year ofcompletion, 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 Fiat there is a construction lending agency for the performance
.O I, as.owner of the property, am exculsively contracting withlicensed contractors to construct theproject(Sec:.
- - -•ol the work for which this permWis issued (Sec. 3397; Civ. C.). -
7044, Business and Professions Code: The Contractor's. License Law does not apply loan 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 •
n -
Contractor's License Law.).
Lender's Address
O 1 am exempt under Sec:' B..B P.C. (Attached Certificate).
J certify that I have read this application and state uat the above information is correct: I agree to comply with all
Date Owner ' "S
city and county ordinances and state laws relating b building construction, and hereby authorize representatives
"enter
of this county. to upon the above=mentioned rroperty for inspection purposes.
WORKERS'. COMPENSATION DECLARATION:'I hereby affirm that I have a certificate of consent to sell insure: ora
.. ..
'-certificate of Woikers' Compensation-Insurance",or a certified copy thereof (Sec. 3800. Lab. C.): :t
Signature of Applicant o(Agent Date
Policy No, Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: -I certify l h ave read this application and state that "
O Certified copyis•hereby furnished.:
the information given is correct: I agree to comply vith all state laws and county ordinances relating to buidling
O Certified copy is filed wilh.the City Building Inspection Department or.City' Department.
construction, and authorize a'represenlative of the City ofLa Ouinla Department of. Building and Safety to enter
.. . . .Y
' upon the. property for which I have applied for this permit for the purpose of making inspections.
Date Applicant'
-
Signature of Applicant or Agent Date
APPLICANT NAME
✓P!L ��
ADDRESS
�y
a�fJy`Mr/SY)�SG
roe I �'Aoor�E spAcg 1-
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CITY/COOMr MUV/STATE/ZIP '
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PRC
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T`RRAAC�T/� �}
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MOD
SB
TRACTNAME'
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME'
ADDRESS
CITY/COMMUNITY/STATE/ZIP '•
PHONES � //
tolICNC—'"/'
ARC/ENGIFFIIIRRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP - -
PHONE •
LICNC •
'
USE OF PERMIT'
BL
ZON •
FS8 •..' .SS8
SSB
RSB
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. ZONE.ORD:n' �..
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END
SIDE
Print Applicant/Agent Name
' APPL/PRMT .04 q q' //7
/ I V J
7rJ C3�//c/,� St -'•9 ;q S p,�,P
. YEA C,�! ���., oa •
TOTAL`
FEE •
BLDG. DEPT.
VALUATION 1" QD'r�D
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 136
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
tiv-M/J.
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
PSL P/1
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final