0353 (RPL)PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
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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
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
Lic Number
Dale Contractor
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 theirsole compensation, will do the work, and the
structure is not intended or offered for sale (Sec 7044, Business and Professions Code: The Contractors 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 11, 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, 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).
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 acertlfied copy thertiol (Ser:. 3800. Lab- C-).
Policy No _ Company
EN:eitified copy is hereby furnished. ,
U Certified copy is filed with the City Building Inspection Department or City Department.
Dale Applicant
APP NT NAM{L, F. MI)
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C'T2OMMiI� ITY/STATE/ZIP
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CITY/COMMUNITY/STATE/ZIP
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TRACT NAME
OWNER NAME (L. F. MI)
CONPIT TOR -FIRM *I?����i'j
ADDRESS
CITY/CQMMUNI /STATE/ZIP
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PHONF�/1
LICNC N /
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC N
USE OF PERMIT
BL I
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FSB SSS
SSS
RSB
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ZONE ORD a
LOT SZ
END
SIDE
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION 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.
Date Applicant
NOTICE TO APPLICANT: 11, 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 or this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
0 1 hereby certify that no excavation live (5) ormore 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 buflding structure, scaffolding, falsew ork, or
demollllon or dsmantling thereof, will be more than thirty-six 1351 feet high. IChap 3 2, Grp 2, Art 2. Sec341, Tifle B,
C-A-C-)
El 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 perfotmance
of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's blame
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
APPVPRMT r
DA
� r Y
TOTAL
FEE
�Tr
VALUATION /)
BLDG. DEPT.
NO.
OPERATION
DATE INSPECTOR
NO.
OPERATION I
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
34
Plenums & Ducts
2A
Slab Grade
35
1 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. ❑
OP'N ADDITIONAL INFORMATION
NO.
/C I//7%3 �Y
F `
n n -1 / A.--
SEWAGE SYSTEM SIZE & LOCATION
11
Exterior Lath
12
Internal Lath
12A
Drywall
13
Finish Grade
INSULATION
Thick
Value
al
7A
Walls (Batts)
Ceiling (Batts
1
1
12C
Ceiling (Blown)
14
Final
PLUMBING APPROVALSC.
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
PjL PI:
STREET NAME
26
Power Pole
27
Conduit
28
Service Entrance
29
Wiring
29A
Grounding Wire
29B
Bonding
30
Fixtures
31
Service
32
Final