0495 (RPL)r � .
AD A/W
PERMIT APPLICATION
City of La Ouinta
>o Department of Building and Safety
j,
PAG/yC)
This permit becomes void if work not commenced within- 180 days from date of
issuance. OR, Wwork has been suspended or abandonec for a period of 180 days.
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE:- This section neednotbe completed if
LICENSEO'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 forwhich 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 mannerso as to become subject tothe Workers'.Compensation.Laws of
and effect. ;Z�pi//
California.
K License Class ' L•ic.'Ntmber
Date Applicant
r
• Date Contractor
NOTICE TO.APPLICANT: If -after -making this Certifi :ate of Exemption, you should become subject to the Workers"`
' OWNER=BUILDER DECLARATION: I hereby affirm that' I am exempt from. the Contractors License Law for the: , '
Compensation provisions oLthe_ Labor Code, you Rust forthwith comply.with such provisions or this permit shall_ '
be 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 -its issuance: -also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY- PERMIT,CERTIFII:ATION....
•• such permit to file asigned statement that he is licensed pyrsuant to the provisions of the Contractor's License Law,
b 'I hereby cirldi thafr-6 excavation five'S)ormore feet in depth into which a person is required to descend, will be
(Chapter 9 (commencing with section 7000j of Division 3 of the Business and Professions Code)or that he is'exempt., •
made'in connectiori 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 Sectiom7031.5 by any applicant for a permit •
demolition or dismantling thereof,-wiII:be more lhanfhirty-six (36) feet high. (Chap 3.2; Grp 2,'Art 2, Sec341, Title 8; '
subjects the applicant to a civil penalty of not more than five hundred dollars ($500:):
'C.A C) x ,c'r :•
O I, as owner ofthe property, or my, employees wittuwages as their sole compensation; will do the work, and the.
O As'owner-builder, I will not employ anyone to Jo work -which would require a permit from the Division of
structure is not intended or -offered for sale (Sec.7044, Business and Protessions•Code:The Contractor's License
Industrial Safety,'as noted'above,.unless such'pernon 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
- .
' through his own employees, provided that such improvements are not intended or offered for sale. If: however; the.
o, Division of Industrial Safety Permit No:
' building orimD.rovemntissoldwithinoneyearofcompletion, the owner -builder will have the burden ofprovingthat. -:
Date' :Applicant..
he did not build or improve for the purpose of sale.)..
CONSTRUCTION LENDING AGENCY: I hereby affirm Kiat there is a construction lending agency for the performance
O 1, as owner of'the property, am exculsively contracting with licensed contractors to construct the.project (Sec.:
of the'work for.which this permitis issued (Sec. 3x97; 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 Fam exempt under Sec. '• : B. B P.C. (Attached Certificate).
I certify that l have read this'application and state flat 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=nrentioned Iroperty 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'tnereof (Sec. 3800. Lab. CJ. .
Signature of Applicant or Agent ' Date
Policy, No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:' I certify.) 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 City. Building Inspection Department -or City Department..
construction, and. authorize a'representative otthKilyof La Ouinta Department of Building and Safety to enter.
for for for the inspections!
z -
Date Applicant
upon-the'property which I have applied this 1permit purpose of making
Signature of Applicant or Agent Date
Print Applicant/Agent Name ,
AP H/gI /4E,;N
AD A/W
CILr/CO u lTY/STTAA;rlR
/ ('J
JOB SITE ADDRESS/SPACE
v H✓� l�iST�' '7' Al
'CITY/;OMMMUNITY[STATE Z P .. -
BOK•`
PAG/yC)
PRCC
TWN
RNG•
SE
S
TRACT
LO
MOD
.SB
.
TRACT NAME
OWNER NAME (L. F. MI) -
CONTRACTOR -FIRM NAME •, ' - - .. .. -
ADDRESS -
CITY/COMMUNITY/STATE/ZIP
P,N�l:.�
ARC/ENG FIRM NAME - - -
ADDRESS -
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC N
'
USE OF PERMIT
BL
•ZON
-FSB
SSB
SSB.
RSB
OFC
dONE'ORD �`•. -'
-
LOT -SZ -
.END
SIDE
•APPLJPRMT%i 9, 1/ DE / S� /1
� men /7 TO. /N S 7141- G -SA, 4d S X45
TOTAL '
FEE'
'tea
VALUATION s�J OD•C/O,
BLDG.DEPT.
w
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.
❑
N
NO.
O.
ADDITIONAL INFORMATION
e' �
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 PiI
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
298 Bonding
30 Fixtures
31 Service
32 Final