0572 (RPL)PERMIT APPLICATION
City of La Ouinta
'T
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 tor.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, 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 farce _
issued, I shall not employ any person in anymanner so as;to become subject to the Workers' Compensation Laws of
and effect.
California.
License Class Lic. Number
Date Applicant .
'Date Contractor " • -
NOTICE TO APPLICANT: If, after making this Certificate. of -Exemption. you should become subject to.,the,Workers'',
OWNER-BUILOO'DECLARATION1• I hereby affirm that I am exempt from the Contractor's License Law for the
Compensation provisions of the.Labor Code, you must 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
be deemed revoked. . •
construct, alter, improve, demolish: or repair any structure, prior to its issuance, also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFIC.,TION:
such permittolileasignedstatementthatheislicensedpursuanttotheprovisionsoftheContractor'sLicenseLaw
I hereby certify that no excavation five (5) or more t --et in depth iniQ Which a person is required to descend, 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 per 1, and that no building structure, scaffolding; falsework, or
_ therefrom and the basiscfor the alleged exemption. Any violation of Section 7031:5 by any applicant for a permit.
demolition or dismantling thereof, will be more than Dirty-six(36) feet high. (Chap 3.2, Grp Z. Art 2, Sec 341',Title 8,
subjects the applicant to -a civil penalty of not more than five hundred dollars ($500.):
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 o'Wner-builder, I will not employ anyone to db work which would require a permit from.the Division'ot .
• structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License. ...
Industrial Safety, a`s'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.
.r.
through his own employees, provided that such improvements are not intended or offered for sale. IL however, the . n
O Division .of Industrial Safety Permit No.
building or improvemnt is sold within one year of completion, the owner. -builder will have the bvEqen of proving that
Date' —Applicant'
_ he did not build or improve for the purpose of sale.); . f
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
O 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. 30!7,.Civ. C.).-
.).47044;Business
7044.-Businessand Professions Code: The Contractor's License Law does not apply to an owner of property who
Lender'sName
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
' O l am exempt under Sec.. B. 8 P.C..(Attached Certificate)..
I certify that I have read this application and state th.t the above information is correct. I agree to comply with all
.Date Owner,
city and county ordinances and state laws relating tobuilding construction, and hereby authorize representatives -
..
of this county to enter upon the above-mentioned p.operty for inspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure. or
.
'• 'certificate of Workers' Compensation Insurance% or:a certified copy thereof (Sec. 3800. Lab-. C.). -
Signature of Applicant or Agent Date
Policy No. Company
CERTIFICATE OF COMPLIANCE'AND AUTHORIZATION )F ENTRY: I certify I have read this application and state that
O.Certified.copyfis hereby' furnished. i� '. , T
/y, '
the.information, given is correct 1, agree to comply w th all state laws and county ordinances relating to buidling
construction,.and,authorize a representative'oi the :ity of La Ouinta Department of Building and Safety to enter
' O Certified co s Th ed', the City Building Inspec i nTepar ment or Clty�`' �' /Department.„
f . lyj }! -`
upon the.proDer(y for which I have applied focihis rermit for the purpose of making inspections.
Date /' Applicant
T
Signature of Applicant or Agent Date
APPLI ANT NAME (L. F, MI)
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ADDRESS
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CITY/COMMUNITY/STATE/ZIP - •.
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TRACT NAME
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0 NAME (L. F, MI) .
CONTRACTOR -FIRM NAME • . .
ADDRESS .,
CITY/COMMUNITY/STATE/IIP ,
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ARC/ENG FIRM NAME .. ..
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
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USE OF PERMIT -
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END
SIDE
Print Applicant/Agent Name
APPUPRMT - S > . /
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TOTAL
FEE
. 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.
❑
NPON ADDITIONAL INFORMATION
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'
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade -
INSULATION Thick Value
7A Walls (Batts)
128 Ceiling.(Batts)
12CT 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/t
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring.
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final