0486 (RPL)10
APPLICANT NAME (L. F. MI(.11) -
AAJ DF/G,r ((V 0 In Pt
ADDRESS.�
49-42_9 r r 0 l�s 1-'A16,A)r?''t9
PERMIT APPLICATION
l� City of La Ouinta
Department of Building
and Safety
c
PRC
This permit becomes void if work not commenced within 180 days from date of issuance. OR, if work has been suspended or abandone[ for a period of 180 days.. .
., -
CERTIFICATE OF EXEMPTION FRO M.WORKERS' COM'ENSATION INSURANCE:.This section need not be completed if
LICENSED CONTRACTORS. DECLARATION: Lhereby 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 Sof the Business and Professions Code, and my license is in full force
issued, I shall not employ any person inany manner -so as.to become subject to the Workers'Compensation Laws of .
and effect.
California. -
License Class. Lic. Number
Date Applicant:
DateContractor ,,.r
y •rr
NOTICE TO APPLICANT: If, after making this Certifi..ate of Exemption; you should become subject to the Workers' ,
OWNER -BUILDER DECLARATION: Thereby affirm that I am exempt from the Contractor's L'icense.Law for the `
Compensation provisions of the Labor Code: you most forthwith comply with such provisions or this permit shall
�'Tbe deemed revoked.
following reason (Sec. 7031.5. Business and Professions Code: Any.city or county which requires a permit to
ADDRESS
construct, alter, improve, demolish, or repair any structure, prior to itsissuance, also requires the applicantdor •.
DIVISION OF INDUSTRIAL. SAFETY PERMIT CERTIFICATION:
such permit to file a signedstatemenbthatheislicensedpursuanttotheprovisionsoftheContractor'sLicenseLaw
01AeretI certifythat no e9cavation five (5) or morEfeet in depth into which a pdrson is required 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 woik 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 applicanttor. a permit �,;•T �':
demolition or dismantling thereof, will be more than shirty=sik (36) feet high. (Chap 3:2, Grp 2 Art 2, Sec341, Tille8:
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
C.A.C.
0 I. as owner of the property, ormy employees with wages as their sole compensation, will do the work, and the,
0 As owner -builder, I will'not employ anyone to to work which would. require a permit from tNe Division of ..
structureis. 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 -from that division.. •.
Law does not apply to an owner of property who builds, or improves thereon, and who does such work himself or
ZON
'through his owmemployees, provided that such improvements are not intended or offered for sale: If, however, the.
0 Division of Industrial Safety Permit No.
building or improvemnt is sold within one year of completion, 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: 1 hereby affirm Prat there is a construction lending agency for the performance "
0 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. 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
0 I am exempt under Sec. : B. & P.C. (Attached Certificate).
I certify. that I have read this application and state that the above information is correct. I agree to, comply with all
Date " Owner
cityand county ordinances and state laws relating t. building construction, and hereby authorize representatives
of this county to enter upon the above=mentioned• property for inspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a.
certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. C.). N-
'. of Applicant or Agent "date
Policy No. Company ._
CERTIFICATE'OF COMPLIANCE AND AUTHORIZATIONfOF ENTRY: i certify I have read this application and state that
0 Certified copy is hereby furnished. ..
the information given is correct. I agree to comply v, ith all state laws and county ordinances relating to buidling
0 Certified copy is filed with the.City Building Inspection Department or City' Department.
construction: aAd.authorize a'representative of the City -of La Ouinta Department. of Building and Safety to enter.
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upon the property for which l have.applied for this permit for the purpose of making inspections.
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Dare Applicant•
..
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_
Signature of Applicant or Agent Date
10
APPLICANT NAME (L. F. MI(.11) -
AAJ DF/G,r ((V 0 In Pt
ADDRESS.�
49-42_9 r r 0 l�s 1-'A16,A)r?''t9
CITY/COMM//UNI''TY/STATE/ZIP '
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OWNER NAME (L. F. MI) _ ..
CONTRACTOR -FIRM NAME
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ADDRESS
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Print Applicant/Agent Name
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TOTAL
FEE
BLDG. DEPT. VALUATION
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.
❑
OP'NO. ADDITIONAL INFORMATION
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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 Pel
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final