0496 (RPL)w PERMIT APPLICATION
City of La Ouinta
r j Department of Building and Safety
-This permit becomes void if work not commencedwithin 180 days from date of issuance. OR, itwork has been•suspended or abandoned :or a period of 160 days
. . f,I1 - . -. ...
- CERTIFICATE OF EXEMPTION FROM WORKERS' COMPI NSATION INSURANCE:. This section need notbe completed if -
LICENSED CONTRACTORS DECLARATION: 1 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 force
issued, I shall not employ any person in any manner saasto become subject to the Workers' Compensation Laws of
and effect.
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California.
Applicant
License ClassIc!Number -
•�
-„ Oate ' - Contractor2f . LrJ R7` n
A
Date
NOTICE TO APPLICANT: ;If, after making this Certificc teal Exemptipn—you'should become subject to the Workers'
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OWNER-BUILDERDECLARATION: I' hereby.affirm that.]. am exempt from the Contractor's License Law for the
Compensation provisions of the Labor Code,. you mu_ t forthwith comply with such provisions or this permit shall
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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.kTION:
'such. permit to file a sig nedstatement that he is licensed pursuant to the proyis ions of the Contractor's License Law , .
. -' b I hereby ciady1hat no excavation five (5) or more - -eet'ih depth intowhich a person is required to descend, will be
(Chapter 9(commencing with gection.7000) olDivision 3 of the Business and Professions Code) or that he is exempt
made in connection'with work authorized by this permit; 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 for a permit
'demolition or,dismantling thereof, -wilt be more than tiirty-six (36) leethigh. (Chip 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:) '
- q 1. as owner of the property; or my employees with wages as their sole compensation,.will do the work, and the:: r ••.
•' D As.owner-builder; I will:not employ anyone. to ao 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 work from4hat division.
Law does not apply to an owner.of property who builds, or improves thereon, and who does such work himself or.
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• through his own employees; provided that such improvements are not intended or offered.for.sale. If, however, the
0 Division, of Industrial Safety Permit No.
building or improverrint is sold within one year of completion,.thjq owner -builder -will have the burden of proving that .
Date '- Applicant -
he did not build . improve for the purpose of sale.). :r„ - E
CONSTRUCTION LENDING AGENCY: I hereby affirm Mat there is a construction lending agency for the performance
D 1; as owner of the property, am exculsively contracting with licepsed contractors to construct the project (Sec:
of work for which this permit.is issued (Sec. 3097, 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 a contractor(s).licensed pursuant to the
Contractor's.License Law.).
Lender's Address
O 1 am exempt under Sec. B.-& P.C. (Attached Certificate).
A certify that I have read this application and state tht the above information is correct. I agree to comply with all
Date Owner {
city and county ordinances and state laws relating to building construction, and hereby authorize representatives -
of this county to:enter upon the above-mentioned roperty for inspection purposes.' '
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to.self•insure, or a
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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 AUTHORIZATIONDOF 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.Certified copy%is filed with the City Building.lnspection Department or.City ' Department.
construction, and authorize a,representative of the City of La Ouinta Department of Building and Safety to enter
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
Nr`Fj 4L.F/M�Nj�j'S� ASE•$ - .
ADDR 7V -j/2.2 IIIA
clTr��/�N�i1Y/STATE/��1 11t
JOB SI E. ADDR�ESS/SPPA)CE
5/Y'�v �%/F
CITY/CQMMUNITY/$•TATE/ZIP
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PRC
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AND,
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TRACT�
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TRACT NAME
OWNER NAME (L. F. M1) ,
CONTRACTOR -FIRM NAME -
ADDRESS
CITYY/CCOMMMUNITY/STAA_T�E'/Z/IP r• ..1Cli, - ,
PHJ 7r/ �� / ,
/ANO • ���
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-ARC/ENG FIRM NAME
ADDRESS ..
CITY/COMMUNITY/STATE/ZIP
PHONE •
LICNC •
USE OF PERMIT
BL
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FSB.
-SSB
-SSB
,RSB'
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.ZONE ORD 11 • -
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END "'
SIDE. ,
Print Applicant/Agent Name
APPL/PRMT //D SE/J. ,
G14 .17AI. .2 5, ®47
17- 3� .
TOTAL'
FEE •
BLDG. DEPT. VALUATION',2 T040,
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION DATE INSPECTO�
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
34
Plenums & Ducts
2A
Slab Grade
35
Furnace Compact.
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
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SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 ..Interhal 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