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0327 (BLCK)PERMIT APPLICATION City of La Duinta 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:. " _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if LICENSED CONTRACTORS'DECLARATION: I hereby affirm .that I:`am' licensed' under provisions of Chapter 9 - - the permit is for -one hundred (5100) 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.) shall not employ any person in any mannensoasto become subject to the Workers'CompensationLaws of and effect. California. - License Class Lic. Number . Date Applicant Date" ' - Contractor' . NOTICE TO APPLICANT: If, -after making this Certificate of Exemption, you should become subject.to the Workers' . - 'OWNER -BUILDER DECLARATION: I hereby affirm (hat- I am exempt from the Contractor's License Lawfor the ".Compensation provisions of the Labor, Code,�you must forthwith comply with such provisions or this_permit shall ' fie deemed d., 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, DIVISION OF INDUSTRIAL. -SAFETY PERMIT CERTIFICATION: such permit to file a signed statement that he is licensed pursuant to theprovisions of the Contractor's License Law 01 hereby c6rlifVIhAt n6ex6i4tion five (5) or more feet in depth into which a person is rbquired to descend, will be (Chapter 9(commencing with section 7000) of.Division 3 of the Business and-Protessions Code)ar that heis exempt made in connection with work authorized by this perinit`, and that no b0din-gstructure, scaffolding, falsework, or . herefrom and the -basis 'for the alleged exemption. Any violation of Section 7031.5 by.any applicanLlor a permit demolition'or dismantling thereof, will more than thirty-six.(36) feet higho(Chap 3.2. Grp 2. Art 2. Sec341, Title8. subjects the applicant to a^civil penalty of not more than five hundred dollars ($500.): x' "".% C.A.C.) 0 I: as owner of the property, or my employees with wages as their sole compensation, will do the work -,-and the'. ❑ 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 Protessions'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, arid.who does such work himself or r ' through'his own employees, provided that such improvements are not intended or offered for sale. If, however, the 0 Division of Industrial Safety Permit No. • building or improvemnt is sold within one year of completion, the owner -builder will have the burden of proving that Date Applicant ., he did not build or improve for the purpose of sale.). ^ -.1,. CONSTRUCTION LENDING AGENCY: I hereby affirm Ihatthere'isa construction lending agency for the performance 0 I, as owner of the property, am exculsively contracting with licensed contractors to construct -the project (Sec. of -the work for which this permit is issued (Sec. 3097, Civ. C.).. . 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 • 'ZONE ORD I Contractor's License law.).Lender's Address 0 1 am exempt under Sec.. B. 8 P.C. (Attached Certificate). 1 certify that have.read this application and state that the above information is correct. I agree to comply with all Date It 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 DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, ora certificate of Workers' Compensation Insurance ,'or a certified copy thereof (Sec. 3800. Lab. C.). Signature of Applicant or Agent Date Policy No. Company. CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify l 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 relating to buidling D Certified copy is tiled wrj(h the Ity Building Inspection 0 partmem'or•CiY Department, construction, and authorize a'representative of the City of La Duinta Department of Building and Safety to enter X 1/ y� • `� upon the property for which I have applied for thisgermit for the purpose of making inspections>. Date Applicant. ��• Signature of Applicant or Agent 'Date Print Applicant/Agent Name VALUATION BLDG. DEPT. ADDRESS CITY/C 7NITV TA�� ' JOB SIT",//�/JDOpE�S/�PACE- ' CITY/COUMUUNI TYTYY//SSTT/ATLE/ZI P BOK 'PAG PRC C TWN. .RING SE,. S TRACT LOT MOD Se TRACT NAME CONTRACTOR FIRM NA ADDRESS�_J�I/�Gr/� CITY/COMMON TY/STATE/ZIP^ °s"�1 i6®Z3 I`Tis ICNC 77/ ARC/ENG FIRM NAME• ADDRESS CITY/COMMUNITY/STATE/ZIP PHONE 1 LICNC 11 - USE OF PERMIT ' BL ZONFSB SSB SSB RSB OFC' • 'ZONE ORD I LOT SZ -END .' SIDE . Print Applicant/Agent Name 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. ❑ OP'NO. ADDITIONAL INFORMATION ��iN ' SEWAGE SYSTEM SIZE.& LOCATION 11 Exterior Lath 12 Internal Lath 12A Drywall 13 Finish Gradea� 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 PSL P/1 STREET NAME 26 Power Pole 27 Conduit 28 Service Entrance 29 Wiring -29A Grounding Wire 29B Bonding 30 Fixtures 31 Service 32 Final