0697 (SPIN)PERMIT APPLICATIONCity of of La Ouinta
Department of Building and Safety
This permit becomes void if work not commenced within 180 days from date of issuance,.OR, if work has been suspended or abandoned for a period of 180 days.
rt ••- • CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATIONINSURANCE: This section need not becompletedit
LICENSED 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 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 full force issued, I shall not employ any person in any manner so 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 otExemption„you should become subject -to the Workers'
Compensation provisions at the Labor Code, you must forthwith comply with such provisions or this permit shall
OWNER-BUILDERDECLARATION: 'I hereby affirm that I am exempt from the Contractor's License Law for the .' be deemed revoked.
• following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permivto
construct, alter, improve, demolish, or repair anystructure, prior to its issuance; also requires the applicant for DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
such permittofileasignedstatementthatheislicensedpursuanttotheprovisionsoftheContractor'sLicenseLaw-0-1herdby certify that no excavatio - n five (5) or more feet in depth into which a person is required to descend, will be
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) or thal he is exempt : - made in connection with wo7k atithorized by this permit, 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 for a permit : demolition,or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341: Title8.
''+.subjects the applicant to a civil penalty of not more than five hundred dollars (5500.): -” C.A.C.) - 1 .1 - - '
O I, as owner of the property. or my employees with wages as their sole compensation, will do the work;:and the O As owner -builder, I will not employ anyone to do work which would require a permit from the Division of
structure is not 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 himself or
through his own employees. provided that such improvements are not intended or offered for sale. If, however, the ❑ Division of Industrial Safety Permit No.
building orimprovemntissoldwithinone year ofcompletion, the -owner -builder will havethe burden of provingthat. Date Applicant
he did not build or improve for the purpose of sale.).. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
❑ 1, as owner. of the property, am excufsively contracting with licensed contractors to construct the project (Sec. of the work for which this permit is'issued (Sec. 3097, Civ. Q.
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
❑ I am exempt under Sec. A. 8 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 to building construction, and hereby authorize representatives
of this county to enter upon the above-mentioned property for inspection purposes. '
WORKERS' COMPENSATION DECL'ARATION:A hereby affirm that 1 have a certificate of consent to self -insure, or a
certificate of Workers' Compensation Insurance , or a'certified copy thereof (Sec. 3800. Lab. C.). ° c:
Signature of Applicant or Agent Date
Policy No., Company - CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
0 Certified copy:is hereby furnished. the information given is correct. I agree to'comply with all state laws and county ordinances relating1to buidling
O Certified copy is filed with the City Building Inspection Department or City Department. construction; and authorize a' representative of the City of La Ouinta•Department of Building and Safety to enter -
Upon �theJproperty for which 1 ave2pD�lied�for this permitrfor'the purpose of maakkiin inspection's'.
Oate Applicant ��� X I A_ '
Signature of Applica`nt'or'Agentr `Date
Print Applicant/Agent Name f
APPLICANT NAME (L• F+•MI)_
G C pAC C
ADDRESS
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CITY/COMMUNITY/STATE/ZIP
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TOTAL
FEE •
TRACT NAME
OWNER NAME (MI(
'CONTRACTOR -FIRM NAME '
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ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE • '
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LICNC
ARC/ENG FIRM NAME
ADDRESS -
CITY/COMMUNITY/STATE/ZIP
PHONE M
LICNC 11
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-IVED
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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. ❑
P -N ADDITIONAL INFORMATION
NO.
Y�
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
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
P/L 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