0568 (RPL)APPLIC NT NAME
y�/l"J//188
ADDRESS ,r
" t PERMIT
APPLICATION "
City of La Ouinta
Department of
Building and Safety .
PRC
C.
_ .., This permit becomes void'il, work not commenced within 180 days from date of issuance, OR, if.workhas been suspended.or,abandoned.:or a period>o1.180 days: ?'P'
TWN •
CERTIFICATE OF EXEMPTION FROM WORKERSCOMPENSATIOWINSURANCE: -Thisssection need not be completed it. - .. e �
LICENSED CONTRACTORS DECLARATION:.I -hereby affirm that I am •licensed ;under provisions. of Cnapter,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 lull force.,
. , ' issued:.lshall not employ any person in any manner.so asto.become subject,tothe 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{-.:,�. w
OWNER-BOILDER.DECLARATION: Yhereby affirm I at,I,'am exempt from the Contractor's License law lor�the,.'
Compensation provisions of the.Labor Code, you mist forthwith comply with such provisions or thispermit,shall
-
•following.reason (Sec. 7031.5, Business and Professions Code: Any city or,county which requires a permit to
- be deeme0 revoked.
'
' constructs alter, improve, demolish, or repair any structure; prior to its issuance, also requires the applicant for
..:.DIVISION OF INDUSTRIAL SAFETY PERMIT;CERTIFICATION:. ,.
:..such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law ..
0 hereby certify that no excavation five (5) ormoreleet inidpth into which a person is required to descend, will be -
(Chapter 9 (commencing with section 7000) of Division 3 ot.the Business and Professions Code)orthat he is exempt ..
.. made in connection with work authorized bythis'peranit; and th'atno building structuie, scaffolding, falsework, or
therefrom.and.the basis tor'the, alleged exemption.,Any violation of Section 7031.5 by any applicant lona permit . :..
demolition or dismantling thereof: will be more than Thirty-six (36) feet high. (Chap 3.2, Grp 2; Arl'2;Sec341, Titl6B.
subjects the applicant to.a civil -penalty of not more than five hundred dollars ($500.):
C.A.C:)
:.: ❑ 1, as owner. of the property: or Iny employees with wages as their sole compensation, will do the work, and the : .,;
❑ As owner: builder, I will not•employ'anyone to to work which, would°require a permit from the: Division of
_ structure isnot 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 himselI or
r -
❑ No.5.,
through his own employees. provided that such improvements are not.intended or offered.tor sale. If however; the
Division of Industrial Safety Permit
- buildingoomprovemntissold within one year ofcompletion;the owner -builder will have the burdenofpnyingthat ..
Date Applicant
he did not build or.improve for the purpose ofsale.): - +"'
CONSTRUCTION LENDING AGENCY: I hereby affirm Oat there is a construction lending agency for the performance +
❑ 1, 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. 397, 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 lam exempt under Sec.= B. & P.C. (Attached Certificate).
I'certify that thave read this application and state fiat the above information is correct. I agree to comply with all
Date Owner
city and county ordinances and state laws relating:b building construction; and hereby authorize representatives .
of this county to enter upon the above-mentioned rtoperty for inspection purposes. t ry
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent toself-insure;'ora
certificate of'Workers' Compensation Insurance , or a certified copy:thereof (Sec. 3800. Lab. C:).
t
Signature of Applicant or Agent r Date .
Policy No. Company
;.. CERTIFICATE OFCOMPLIANCE AND AUTHORIZATIOPOF' ENTRY: Icertify Ihave read this application and state that ••
❑ Certified copy is hereby furnished. - .
- .the. information, given is correct. I agree to.comply, vith.all state laws and county ordinances relating.to buidling i
{ • '
O Certified copy is filed wit ,the'City Building Inspecbon.Department or/�ity-D@partment
rl
construction, and authorima'representative of the Cit of La Ouinta Department of Building and Safety to enter. "
y p g y
upon the property for which I have applied for thi• permit.torthe purpose of making inspections.
! t
Date (• ApphcanLf(
Signature of Applicant or Agent Date
_
Print Applicant/Agent Name
APPLIC NT NAME
y�/l"J//188
ADDRESS ,r
CITY/COMMUNITY/STATE/ZIP
JOB SITE A0ORCE�SS/SPACEA V • '' •' L ,.
CITY/COMMON STATE ZIP
BOK -
.PAG'
PRC
C.
TWN •
RNG .
SE ;,
S
TRACT
/.yy96 •
LOT
S
MOD
SB
'-
.
TRACT NAME' • -
OWNER NAME (L, F. MI) .. •• .. ,
CONTRACTOR -FIRM NAME ..
ADDRESS
CITY/COMMUNITY/STATE/ZIP ..
PHONE 1 ..i
•
LICNC I
ARC/ENG FIRM NAME
ADDRESS
'CITY/COMMUNITY/STATE/ZIP -
PHONE N
•
,
USE OF PERMIT ,
BL'
ZON'
FSB.
.SSB" i.
SSB_,i ..RSB
OFC'
ZONE ORD
LOT SZ
'END
SIDE'
' y �`: ., • VALUATION
BLDGi DEPT.
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
SEWAGE SYSTEM SIZE,& LOCATION
11 Exterior.Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
128 Ceiling (Batts)
12C Ceiling (Blown)
14 1 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/I
STREET NAME'
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
290 Bonding
30 Fixtures
31 Service
32 Final