0277 (SFD)PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
This permit becomes void if work not commenced within 180 days from dale of issuance, OR, if work has been suspended or abandoned for a period of 180 days,
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force
and effect.
License Class
Dale Contractor
Lic. Number
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for the
following reason (Sec. 7031.5. Business and Prntesslons Code: Any city or county which requires a permit to
construct, alter, Improve, demolish, or repair any structure, prior (o its issuance, also requires the Applicant for
such permit to file a Signed statement that he is licensed p1lrsuarlt to the provisionso} the Contractor'sLiiense Law
(Chapter .9 {commencing with seclion 7,000) of Division 3 of the Business and Prolessions Code) or that he is exempt
[berefrom and the basis for the alleged exemption. Any violation of Seeiinn 7031.5 by any applicant for a permit
subjects.the applfCant to a civil penally of flat more than five hundred #altars ($500.):
❑ I, as owner of the properly, or my employees with wages as their sole compensation, will do the work, and the
structure is not intended or offered for sale (Sec 7044, Business and Professions Code: The Contractor's License
Law does not apply to an owner of property who builds, or improves thereon, and who does such work himself or
through his awn employees, provided that such improvements are not intended or offered for sale. If, however, the
building or improvemnt issold within orTeyear of completion, the owner -builder will havethe burden of proving that
he did not build ar Improve for the purpose of sale,},
I] I, as dwner of the property, am exculsively contracting with licensed contractors to construct the project ISec.
7044, Business and Professions Code: The Corltraetdr's License Law does "I apply to an owner of property who
builds or improves Iherean, and who corRfacls for such projects with a contractors) licensed pursuant to the
Contractor's Llettnse Law,l.
❑ 1 am exempt under Sec. B. & P.C. (Attached Certificate),
Date Owner
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, 38OR Lab, C.),
Policy
Company
❑ Certified copy is hereby furnished,
❑ Certified copy is filed with the City Building Inspection Deport ant or City,- - -- Department.
Date Applicant
APPLICANT NAME (L, F. MI)
Joint
ADDRESS
CITY/COMMUNITY/STATE/ZIP
JOB SITE ADDRESS/SPACE
CITY/COMMUNITY/STATE/ZIP
i
BOOK PAG
PRC
C
TWN
RING
SE
S
TRACT LOT MOD SB
TRACT NAME
OWNER NAME (L, F, MI)
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC N
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N LICNC N
USE OF PERMIT
BL
ZON
FSB
SSB SSB RSB
OFC
ZONE ORD N
LOT SZ
END
SIDE
CERTI FICATE OF EXEMPTI DN PROM WORKERS'COM PEN SATIO N INSURANCE This section need not be completed if
the permit is for one hundred iS100) o, less, 1 certify Ihat in the performance of the work for which this permit is
issued. I shall not employ any person in any m a nner so as to beco mo subject td the Warke rs' Compensation Laws of
Calilernla.
Date Applicant
NOTIGETO APPLICANT: If, after making this Cerlificale of Exemption, you should become subject to the Workers'
Compensatlon provisions of the Labor Code, you must forthwith comply with such provisions orthis permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I horeby certify that no excava(ion five (5) or moWeotin depth into Which it Pefs00 15 required todasceffd, will be
made In Connection with work authorized by this perm€l, and that no huitdingstructure, scaffolding, falsework, or
damdtitiad.or dismantling thereof, will be more Ihaiithirty-six (36) fear high. (Chap 3.2 Grp 2, Art 2,Sec341, TitleB.
C.A.C.]
❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of
Industrial Safety, as noted above, unless such person has a permit to do such work from that division.
❑ Division of Industrial Safety Permit No.
Data Applicant
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency forthe performance
of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read Ihls application and state [hat the above information is correct. I agree to comply with all
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
of this county to enter upon the above•merdioned property for inspection purposes -
Signature of Applicant or Agent Dale
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and slatethat
the information given is correcL I agree 19 comply with all state laws and county ordinances rafating to buidling
construction, and authorize a 'flepresenlativa of the Clly dt La Ouinta Department of Building and Safety to enter
upon the Brnparly for which I.haae applied far this permlt for the purpose of making inspections:
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMT r'
i
DATE
?r;
{ na
-i,i: aqe
rf 1 t.
_atia Cover
i� f ee
i.�ctric�Ll ,�e�
r2 MO
TOTAL .
FEE
City of La QlAn}a
Arrow Printing 250/1-83 White: Finance Canary: Assessor Pink: Applicant Tag: Bldg. Dept. VALUATION
NO.
1
2
2A
3
4
5
6
7
8
9
10
10A
11
12
12A
13
7A
12B
12C
14
OPERATION I DATE
BUILDING APPROVALS
Set Back
Ftgs & Frms
Slab Grade
Steel
Grout Blocks
Bond Beams
Roof Deck
Framing
Vents
Garage Fire Wall
Fireplace P.L.
fireplace T.O
Exterior Lath
Internal Lath
Drywall
Finish Grade
INSULATION
Walls (Batts)
Ceiling (Batts)
Ceiling (Blown)
Final
a
0
Thick R
Value
PLUMBING APPROVALS
INSPECTOR NO.
OPERATION I DATE
INSPECTOR
MECHANICAL APPROVALS
33
Ventilation System
34
Plenums & Ducts
35
Furnace Compart.
36
Inlets & Outlets
37
Combustion Air
38
Compressor
39
Appl. Clearance
40
Fire Damper
41
Smoke Detection Device
42
Commercial Hood
43
Final
OP'N
NO.
ADDITIONAL INFORMATION
1 J,q
15
Ground Plumb
16
Water Piping
17
Rough Plumb
18
Vents
19
Sewage Disposal
20
Sewer
G
,!
21
Water Heater
22
Water Softener
23
Water Service
24
Gas Test
'
2 I -A- 1/
!Y`
25
Final
ELECTRIC APPROVALS
26
Power Pole
27
Conduit
28
Service Entrance
29
Wiring
29A
Grounding Wire
29B
Bonding
30
Fixtures
31
Service
32
Final
SEWAGE SYSTEM SIZE & LOCATION
Tank Pit L. Line
REAR OF PROPERTY LINE
PIL PIL
STREET NAME