0498 (RPL)APPUCANT,N-A E.(Lb 1 5 * ' 5 ... 4. w. . ", ., . . I. . . - . .
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A
ADOREM
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PERMIT APPLICATION L.
City of La Quinta
Department of Building and Safety
BOK -
PAG PAC -
Jhis:permil becomes -void if work not commenced,within 180.days.from 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' COMPENSATION INSURANCE', This section 'need not be completed %
LICENSED -CONTRACTORS DECLARATION: I hereby. affirm shat .1 am licensed. under provisions of - Chapter, 9 :.,'-,the
�h
,permit is,for one hundred ($100) o, less. I certify :hat in.the performance.of the.work for which this permit is;
n ce se mfull force.
(commencing with Section 7000) of Division 3 of the Business and Prolessiogs.Code, a d Ii n
.,:.Assued, I shall not employany. person in any manners. as to become subject to the.Workers'Compensation Laws of..
and effect. -7
California.
.License Class Lic. Numb4er.
Date Applicant.
Date Contrac!Oi.
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' -
OWNER -BUILDER DECLARATION: - I hereby affirm that I am exempt frorn'the66mracfor's License Law for the'
_e:
Compensation provisions of the Labor Code; you must forthwith comply with such provisions or this permit'shall
0.
be deemed revoked.
following reason (Sec. 7031.5, Business.and Professions Cod Any city or county which requires.a permit.to.
CITY/COMMUNITY/STATE/ZIP
construct- Aer;-impiove, demolish, or repair any structure, prior to its issuance; also requires the applicant for •
DIVISION OF INDUSTRIAL SAFETYPERMIT CERTIFIC.TION:
sych.peirmitto file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law
. . . . I I . .
'�o I depth into w I W
hereby'cerlify that no excavation fiVe (5) or more t --et ir� hith a person is required to dekend, wit
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and.Professions Code) or that he is exempt.
(Cha
.
in de*in 'conn 'tion with work authorized by pdrinit'and that no building structure, scaffolding, falseworkor
a ec . . I
ther efrom arid d the basis for the alleged exemption. Any violation of Section 7031:5 by any.,applicant for.a:permit,
demolition or dism5nilir(g thireof,'will be more than I.iirly -sii (36) feet high. (Chap 3.2. Grp Z*Art 2, Sec34VTiIIii8,,', :,:
subjects the applicant to a civil penalty of not more than five hundred dollars
C.A'C.)'
-.0 Las owner of the property, or -my employees with wages as their. sole compensation, will do,thework, and the
0 As owner -builder; I"will not employanyoneto dD work which Would require a permit from the. Division 'of
structure is not -intended or offered for sale (Sec: 7044.. Business and...Protes-sions-Code:.The, Contractor's License
Industrial Safety, as noted above, unless such pers-n has a permit to do such work from that division. -
Law does not apply to an owneriof property who builds, or improves thereon, and who does such work himself or
"
through his own employees, provided that such improvements are not intended or offered for sale. lf..however, the
of Indusirial.Safei P rmit'No k
y, e
ty, e
-building.or improventrit issoldwithin one year of completion, theowner-builder will have the burden of proving that
Date = Applicant
he.did not build or improve for. theur oseofsale:).-
p
I hereby affirm ttat there
CONSTRUCTION LENDING AGENCY: is a construction lendi6dagency for the performance
0 1, as owner of -the property, am exculsively-cqntracting with licensed contractors to construct the project (Sec.'
of the work for which this permit -is issued (Sec. 30-97, 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 acontra6lor(s) licensed pursuant to the
Contractor's License Law.). ...... I . . : . . . . ,
Lender's Address
-0 lam exempt under Sec. - ''..B. & P.C.,(Allached Certificate)..
I certify that Lhave read this application and state that the above information -is correct. I agree to complywilh all,,
I—' .. -, I
Date" ` per,
city and county ordinances and state laws relating tc building construction, and hereby.authorize representatives,-..-
of'this county to enterupon the above-mentioned III - operly for inspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, ora
'certificate.of Workers" Co mpensati on Insurance , or alcertified ,copy thereof (Sec. 3800, Lab. C.).
of
Sigrfature, 'Kpp 'licant drAbent Date -
Policy No. Company
, - , . .:
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify. I have read this application and 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 CityBuilding- lnspeciio , n Department 6r City, :Departmenf. 4.
.
'
construction, and authorize a 'representative of the City of La Ouinta Department of Building and Safety lo.enter .
.
I . - ` - ' ' ' � - -' . .. . . I .
Date t Applicant
upon the -property for which I III ave applied for this permit for Ke purpose of making inspections.
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPUCANT,N-A E.(Lb 1 5 * ' 5 ... 4. w. . ", ., . . I. . . - . .
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ADOREM
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CITY/COMMUNITY/STATFJ.Zgi-
Y_,?VePACE
JO9.SIT.E ADORES I W41
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CITY/COMMUNITY/STATE/ZIP-
BOK -
PAG PAC -
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AND
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S
TRACT
I L!Y.
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TRACT NAME
OWNER NAME (L. F, MI)
CONTRACTOR -FIRM NAME'
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHO E 0
J AT VI&
LICNC a
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 0 .
LICNC 8
USE OF PERMIT
St.
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FSB
SSB
SSB,
RSB'
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ZONE ORD N -LOT SZ
APPL/PRMT
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TI
.VALUATION
y
-BLDG.DEPT.-
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION I DATE INSPr'CTOR
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.
❑
NO.
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)
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 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