0571 (RPL)' - PERMIT APPLICATION •• -
�.I City of La Ouinta
Building Safety
• Department of
and
This permit becomes void if work'not commenced within 180 days from date of -issuance, OR, it work has.been suspended or abandoned f3ra 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. Jess. I certify that in the performance of the work for which•this' permit is:
(commencing with Section 7000) of:Division 3 of theBusiness and Professions Code, and my'license is in full force
issued, I shall not employ any.person inanymanner sa aslo.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 Cerdficete of,Exemption, you should become subject to the Workers' "
OWNER -BUILDER DECLARATION: I hereby affirm tfiatl am exempt from the Contractor's' License Law for the
.'.Compensation provisions of the Labor Code, you mLst 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-iT1ON:
suchpermittofileasigned-statementthatheislicensedpursuanttotheprovisionsoftheContractor'sLicenseLaw
plherebycertifythatnoexcavationfive(5)ormore°eetindepthinto'whichapersonis'requiredtodescend,willbe-
(Chapter 9 (commencing with section 7000) of Divisiorr'3 of the Business and Professions Code) or that he is exempt
made iri connection with work authorized by this permit, and that no building structure, scaffolding; falsework, or
therefrom and the (iasis for the alleged. exemption. Any,violation of Section 7031.5 by any applicant fora permit.
demolition or dismaniling thereof, will be'more than:t-liriy-six (38) feet highi(Chap 3'2, Grp 2, Art 2, Sec 344, 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 owner-buijder, I will *not employ anyone to Do 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 person has a permit to do such•work4rom that division: - • .
Law does not apply to an owner of 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: If: however, the:
O Division ol.lndustrial Safety,Permit No.-
buildingor.improvemntissold within one yearolcompletion. the owner -builder will have. the burden' of proving that -.
:'Date Applicant
he, did not build or, improve for the purpose.of sale.):.
-w. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance.
O 4as owner of the property. -am exculsively contracting with licensed contractors to construct lhe,project (Sec.
-of the work foV which this permit is issued (Sec. 3097, Civ: C:). t '
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 theieon; and'who contracts for such projects' with a contractors) licensed pursuant to the:
_ Contractor's License -Law.).
Lender's Address
• :. O:I am exempt under Sec: - B. 8 P.C. (Attached Certificate).':
I:certify. that I have read'this application and state'llaCthe above information is correct I agree to comply with all
Date' Owner z)
city and county ordinances and state laws relating a building construction:and hereby authorize representatives
SIDE. .
of this county to'enter'upon the above-mentioned properly for inspection purposes.
WORKERS' COMPENSATION DECLARATION:• I hereby affirm thatl.have a certificate oPconsent to self -insure, ora '•
' certificate of Workers' Compensation Insurance , or a certified copy* thereof (Sec. 3800. Lab. -C.). ,
Signaturebf -Applicant or Agent Date
:., P.olicy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATIONOF ENTRY:- I certify I have read this application and state that
EO Certified copy isherebyfurnished. e • ,l _
•' the information given is correct. I agree to comply with all state laws -and -'county ordinances relating to buidling.
O Certifiedlco y is filed with City Building InspecttJ Department _or�C.i-ty "" Department.
✓ �T�
construction, and authorize,a,'representative of the.City of La Ouinta Department of. Building and.Safety to enter
upon the property for which I haveapplied for this permit for the purpose.of making inspections.
Date 1 x rj Applicant `i CP �� �y
'
i
Signature of Applicant or Agent Date
APPLIFONT NAME (1F. MI) .. -
ADDRESS
CITY/COMMUNITY/STATE/ZIP - -
`% /WC'•�-
-JOB SITE AOORESS/SPACE ' -
�1/�-6/S l/ve Uic16- ,�;ooi•fa�
CITY/COMMUNITY/STATE/ZIP - • ..
BOK
PAG
PRC -
'C
-
TWN...
RNG
SE_
S
.TRACT
/el
LOTMOD
53
SB
TRACT NAME
OWNER NAME (L. F. MI) '
CONTRACTOR -FIRM NAME
ADDRESS--
CITY/COMMUNITY/STATE/ZIP .. '
PHONE •
3 ,07Z_ q96
LICNC 1
ARC/ENG FIRM NAME
ADDRESS '
CITY/COMMUNITY/STATE/ZIP '
PHONE •
LICNC M
USE OF PERMIT
BL
i
ZON
FSB
SSB
SSB .
RSB
OFC"
• ZONE ORD 1
LOT SZ
..
.END .
SIDE. .
Print Applicant/Agent Name
'APPUPRMT - flS, 1 I/DATE
Godes,
.Sp�cL Ae^o".,f'
3 91.ee5
r TOTAL
FEE
VALUATION
BLDG. 0EPT.
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.
❑
NON -ADDITIONAL INFORMATION
3
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
_
P/L 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
0