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0315 (RPL)PERMIT APPLICATION City of La Ouinta Department of Building and Safety This permit becomes void if work not commenced within 180 days from date 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 licensedunder 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 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 pursuantto the provisions of the Contractor's License Law (Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) or that 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 of not more than five hundred dollars ($500 ): ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds, or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvemnt is sold within one year of completion, the owner -builder will have the burden of proving that he did not build or improve for the purpose of sale.). ❑ I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec- 7044, Sec7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law.). ❑ 1 am exempt under Sec . B. 8 P.C. (Attached Certificate) Owner WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. C.), Company 6-fertified copy is hereby furnished - El Certl0 d copy is filed with the Clly Building Inspection Department or City Department. Dale Appllcant - LICANT NAME (L, F, MI) I 24) 17 ADDRESS CIT//YIZOMMUNITYISTATEMP 1-7'? JOB SITE ADORESSfSP7f././ VC CITYrCph1MUNITWSTAT.1�IZIP BOK PAG PRC C TWN PING SE S TRACT LOT MOD SB TRACT NAME OWNER NAME (L. F_ MIl CONTRACTOR -FIRM NAME �y ADDRESS .+� 'r JJ II CITYlC UNITr!$TATErZIP f PHISE N` _201— ARC/ENG FIRM NAME ADDRESS CITY/COMMUNITY/STATE/ZIP PHONE N LICNC N USE OF PERMIT BL ZON FSB SSB SSB RSB OFC City of La Quinta ZONE ORD N LOT SZ ' END SIDE CERTIFICATE OF EXEMPTION FROM WORKERS'LOMPENSATION INSURANCE: This section need not be completed if the permit is for one hundred ($100) o, less. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. 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 forthwith comply with such provisions orthis permit shall be deemed revoked. DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341, Title8, 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, Applicant CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the 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 this application and state that 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-mentioned property for inspection purposes. Signature of Applicant or Agent Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that the information given is correct- I agree to comply with all state laws and county ordinances relating to buidling construction, and authorize a representative of the City of La Ouinta Department of Building and Safety to enter upon the property for which I have applied for this permit for the purpose of making inspections Signature of Applicant or Agent Print Applicant/Agent Name Date APPL/PRMT All _201— G AM I Y City of La Quinta ' TOTAL FEE VALUATION BLDG. 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. ❑ NOADDITIONAL INFORMATION SEWAGE SYSTEM SIZE & LOCATION 11 Exterior Lath 12 Internal Lath 12A Drywall 13 Finish Grade INSULATION Thick Value 7A Walls (Batts) Ceiling (Batts) q12B 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 Phi STREET NAME 26 Power Pole 27 Conduit /Q 28 Service Entrance 29 Wiring 29A Grounding Wire 29B Bonding 30 Fixtures 31 Service 32 Final �� �' ✓ )