0570 (RPL)APP ICAANT NAAI�1�ME/t� MI))
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ADDRESS
I. -PERMIT
APPLICATION '•' ,'
City of La Ouinta
t• Department of
Building and Safety
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- This permit becomes. void if work not commenced.within 180 days from.date.of
issuance. OR, if work has been -suspended ocabandoned fc'a period of 180 days. •..' ., ••. = ^• ' `"
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CERTIFICATE OF EXEMPTION FROM WORKERS; COMPENSATION INSURANCE: This section need not be completed if
. L'ICENSED`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 hat in the performance of the work for which this permit is
• : (commencing with Section 7000) of Division of the Business and Professions Code, and my license is in full force
issued, I.shall not employ any person inany mannerst 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 -BUILDER DECLARATION: I hereby affirm that I am eiempt'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 • r
be deemed revoked.
following reason (Sec..7031.5. Business and Professions Code: Any'city or county which requires.a permit to
• • 1constiuct, alter, improve, demolish, or. repair'any,structure, prior to its issuance; also requires.the:applicant for.'....
DIVISION OF INDUSTRIAL,SAFETY PERMIT CERTIFICATION: ,
` su ch permit to tile a signed statement that h e is licensed pursuant to the provis ions of the Contractor's License Law,•.;.
•-•':O'Iherebycertify'thatnoexcavationfive (5).ormore feet indepth into which aperson isrequired todescend:wilibe.-
' (Chapter 9 (commencing with section 7000) of Oivision.3 of the Business and Professions Code) or thkhe isexempt, :.
-in ade'in.connection with work authorized by this pernil, 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 fora permit '
} •, ,demolition.or dismantling thereof, will be.more than flirty -six (36) feet high. (Ctfap 3.2, Grp 2, Art 2, Sec 341, Titlefl,
subjects the applicant to a civil penalty of not more than five hundred dollars (5500.)::IG:A}C.)
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,,': O.A. as�owner of the property, or my. employees with wages as their sole compensation,.will.do the work, and the
❑. As owner -builder, Twill not employ'anyone to d., work: which would require a permit from the Division of,:. '
'structure is not intended or offeredfor, sale (Sec. 7044, Business and Professions Code: The Contractor's License .
;. Industrial Safety, as noted above,.unless such persci 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
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"through his own employees: provided that such improvements are not intended:ar offered for sale: If, however, the- -
O Division of Industrial Safety Permit No. '
building or improventnt is sold within oneyear of completion, the owner6builder will have the burden of proving that .
Date Applicant
.,;.he did not build or improve for the purpose of safe.). :
CONSTRUCTION LENDING AGENCY; I hereby affirm th it there.is a construction lending agencyfordhe performance +
O l: as. owner of the property: am exculsively contracting with licensed contractors to construct the project (Sec:. •
of the work tor -which this'permil-is issued (Sec.30G7, Civ: C.).' Ii . .
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 contractor(s) licensed pursuant to the
.Contractor's License Law.)..
Lender's Address
❑ 1 am exempt under Sec. ' % : B. 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
city and county ordinances and state laws relating toibuilding 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 thave a certificate obcoosent to'self-iosure,.or a
• certificate of Workers' Compensation insurance , ora certified copy -thereof (Sec: 3800. Lab. C:)., ..
Signatuie of Applicant or Agent r .'Date '
PolicyNo._ Company.
-CERTIFICATE OF COMPLIANCE AND AUTHORIZATION )F ENTRi:.l certify I have read this application and slatethat.' "
O Certified copy:is hereby furnished: ,. -
D Fartment.:
...• the.information given is correctrl agree to comply % ith all state laws and county ordinances relating to buidling �� •.
representative the ;icy La Duinta Department Building Safety
❑ Certified`% copy, is•filedfwith the City Building Inspection artment o -City
construction, and authorizeza of of of and -to enter
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Date �7 Applicant /tJ �i3"trvt
upon the property.for'which9 have applied for this oermit.forthe purpose oCmaking inspections. r
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Signature of Applicant or Agent. Date '.
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Print Applicant/Agent Name , J
APP ICAANT NAAI�1�ME/t� MI))
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ADDRESS
CITY/COM%MIiTY /STA��ZIsP �? , i�-
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TRACT NAME
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OWNER����+AME ,(y•. F. MI)
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CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP'
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ARC/ENG FIRM NAME _
ADDRESS
CITY/COMMUNITY/STATEJZIP
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1 . VALUATION 2 SDD1� EJO
BLDG.'DEPT':.
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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.
❑
NO ADDITIONAL INFORMATION
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SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 .Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick al
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/I
STREET'NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final