0414 (RER)PERMIT APPLICATION
City of La Duinta a
Department of Building and Safety rI
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 ($100) o•.Iess: Lcertify-that in the.performance of the•work for which this permit is
"(commencing with Section 7000) of Division.3of the Business and Professions Code, and my license is in -full force issued. I shall not.empfoy any person inany mannerso asto become subject to the Workers'Compensation Lawsof
- License Class Lic. Number
.T Date Contractor
_ OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt froiriihe-Contractor'slitense Law for the
following reason (Sec..7031.5. Business and Professions Code:. Any pity -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 statemenrthat he is licensed pursuant to the provisions of the Contractor's License Law
.-(Chapter 9 (c6minencingwith section 7000),gf, Div.ision 3 of theBusinessand Professions Code) or that he is exempt •
- ...therefrom and the basis for.the alleged exemption -Any violation -of Section,7031.5 by any applicantfor a permit
• subjects the applicant to a civil penalty of not more than five hundred:dollais ($500:): ..
0 L as owner of.the property, ormy 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 i mprovemnt 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 Lthereon. and who contracts for such projects with a contractor(s) licensed. pursuant to the
-
Contractor's License Law.).
0'6am.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
x:certificate of Workers'. Compensation Insurance", or -a certified•copy thereof (Sec. 3800. Lab. C.).
Policy No.. Company,
0 C�ertified,copy is,hereby furnished.
O'Gertitied copy.is;hledwlth ttieGty,;B,cuilding'Inspectron Departmenbor City - Department..'
Dater ! L`f l,I YJApp licant����
APPLICANT NAME'(L: F, I)
ADDRESS -'
CITY/COMM�UNITY�
ISI�T'E""ADDRESSISPACE
JOB
CITY/COMMUNITY/STATE/ZIP. -
.BON
PAG
PRC i.
C -
TWN
RING
SE
S
TRACT
LOT
TOTAL
FEE
MOD
SB
TRACT NAME
OWNER NA1yy1��E'IL. F, MI) -.-
CONTRACTOR -FIRM NA�M.Ej '. ✓O- �a //�') - '
V
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE a
-ARC/ENG FIRM NAME '•
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE*
- LICNC-f
USE OF PERMIT
BL
ZON
FSB
SSB
SSB
RSB
OFC.'.'
ZONE.ORD �• .'.�
-LOT SZ
•, ENO
SIDE
Date Applicant
NOTICE TO APPLICANT: If, after making !his Certificate,of Exemption, you should become subject to the Workers'
Compensation provisions of.the Labor Code,:you mus[ forthwith comply.with such provisions or this permit shall .
be deemed revoked. S
DIVISION OF INDUSTRIAL'SAFETY.PERMIT CERTIFICATION:
0; I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be
made in connectiolrwith work authorized bythis permit, and that no building structure, scaffolding, falsework; or
+C -'.demolition or dismantling thereof, will be more than thirty-six (36) feet.high. (Chap 3.2, Grp 2, Art 2, Sec341; Title8.
CAC.)
0 As owner -builder, I will hot employ, anyone to do worka which would require a'permit from the Division of -
InduMrial Safety, as noted above, unless such person has a permit to do such.work from that division. '
0 Division of Industrial Safety Permit yo.
Date 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) have readrhis 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,§iveh is correct. I.agree to comply with all state laws and county ordinances relatinglo buidling
construc`ion.and"auth'orizet.a.rep-eseotative of the City of. La Ouinta Department of Building and Safety to enter.
upon'th`e property for Ichf have applied fgr thi� mif t for,the purpose of making inspections. -
G4i •�„_�.� \ / .c—/ y r:%� j
�f Signature of Applicant or Agent /Date
Print Applicant/Agent Name
APPL/PRMT
C1$y 0.1. i a 888
TOTAL
FEE
i
VALUATION ,/irif�� • :/C ).
Y. i. w .-: •s'• BLDG. DEPT..
NO.
OPERATION DATE INSPECTOR
NO.
OPERATION DATE MPECT04
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
U/3
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. ❑
NPON
ADDITIONAL INFORMATION
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
PI PA
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final