0271 (SATT)PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
This permit becomes void it work not commenced within 180 days from dale of issuance, OR, it 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) o1 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 Professions Code: Any city or county which requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Prolessions Code)orthat he is exempt
therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty o1 not more than five hundred dollars (S500-):
L 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 improvemni is sold within one year of completion, the owner -builder will have the burden of proving [hat
he did not build or improve for the purpose of sale.).
❑ I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (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 contracts for such projects with a contractor(s) licensed pursuant to the
Contractor's License Law.).
❑ 1 am exempt under Sec.
Date Owner
B. & P.C. (Attached Certificate),
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 [hereof (Sec, 3800, Lab. C.),
Policy
Company
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the City Building Inspection Department'or City _ Department.
Date Applicant - /
r
APPLICANT NAME (L, F. MI)
,7 8 0
ADDRESS box
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CITY/COMMUNITY/STATE/ZIP r� a 4 5.
JOB SITE ADDRESS/SPACE * `
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CITY/COMMUNITY/STATE/ZIP . . a 77 ��yy
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RING SE S
TRACT I I LOT .
MOD
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TRACT NAME
OWNER NAME (L, F. MI)
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE M 564-1: :
LICNC 4
Ar1CJENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC N
USE OF PERM
_ IT F,, amity Lrwel.lincf
BL
ZON
FSB SSB
SSB
RSB
OFC
ZONE ORD N
LOT SZ
END
SIDE
CERTIFICATE OF EXEMPTION FROM WORKERS" COMPENSATION INSURANCE This section neednot.he completed if
the permit 1s for one hundred (S100) a, less.I certify that in the perfannance of the work for which this permit is
ssu ed, I shall not employ any person in any manner So as to become subject to the Worke rs' Compensa I I o n L aws of
Cafkfornia_
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must lorthwith comply with such provisions or this permit shall
be daemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
I I hereby certify that no excavation five (5) or morafeet in depth into which aperson TS required todescand, will be
made In connection with work authorized by thisper-W,and that no bullCkg strut;ure. scaffolding, falsework, or
demolition or dismantling thereof, will be more than Thirty-six (36) feelh}gh. (Chap3.P, Grp 2, Art 2,Sec 341, Tillefl.
C.ACa
❑ 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 [hat division.
❑ Division of Industrial Safety Permit No.
Applicant
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency lortheperformance
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 this application and state that the above information is correct. I agree to comply with all
city and county ordinances and slatelaws relating to building construction, and hereby authorize representatives
of this county to enter upon the above -mentioned 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 statethat
the information given is correct- I agree to comply with all stale laws and.county ordinances relating to buidling
construction, and authorize a r presentauve of the City of La Ouinfa➢apartment of Building and Safety to enter
upon the property for which Izve appliedJor this permit for the purpose of making inspections,
,Signature of Applicant or Agent
r
Print Applicant/Agent Name
Date
APPL/PRMT ••
. _ t rJ 1
r
„, DA�EF
heck
;ruct-1
4it; .00
:lectrical :e
36.90
A -
6.62
5p.00
430.0o
r^
I
7
Cit Qa I La Quint
TOTAL
FEE
VALUATION
Arrow Printing 250/1-83 White: Finance Canary: Assessor Pink: Applicant Tag: Bldg. Dept.
NO.
OPERATION DATE INSPECTOR
NO.
OPERATION I DATE JINSPECTOR
BUILDING APPROVALS
I
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
Z.
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'N
NO.
ADDITIONAL INFORMATION
11
Exterior Lath
12
Internal Lath
12A
Drywall
c
20 O
13
Finish Grade
INSULATION
Thick Value
7A
Walls (Batts)
12B
Ceiling (Batts)
t�
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
SEWAGE SYSTEM SIZE & LOCATION
1 Tank Pit L. Line
ELECTRIC APPROVALS
26
Power Pole
27
Conduit
28
Service Entrance
29
Wiring
29A
Grounding Wire
29B
Bonding
30
Fixtures
31
Service
32
Final
P
STREET NAME
REAR OF PROPERTY LINE