The URL can be used to link to this page

0103 (RPL)COM ENSATION DECLARATION. I hereby affirm that I have a cerhflcate of consent to self -Insure, or a certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. C.). Policy No. Company O.Certifiecopy is hereby furnished. O Certified copy is filed with the City Building Inspevction Department or City, ( Department. Dat/%_/ 1 i i' j�6 ApplicantX �f�o:cw" ��—IF �F APPLICANT NAME ADDRESS PERMIT APPLICATION r -- '' q , 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, if work has been suspended or abandoned for a period of 180 days. �• PRC 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 (S1OO) 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 anymannerso as to become subject tothe Workers'CompensationLaws of ' and effect. - , � California. •, License Class - Lic. Number Date Applicant- DateContractor NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' OWNER -BUILDER DECLARATION: 1 hereby affirm that I am exempt from the Contractor's License Law for the Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall , following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to be deemed revoked. , 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 the provisions of the Contractor's License Law 01 hereby certify that no excavation five (5)ormore feet indepth into which aperson isrequ 'red todescend, will be (Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) or that he is exempt made in connection with work authorized 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, Title B. subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): - C.A.C.) 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, acid who does such work himself or BL through his own employees, provided that such improvements are not intended or offered for sale. If, however, the O Division of Industrial Safety Permit No. building orimprovemntissold within one year ofcompletion, the owner -builder will have the burden of proving that Date Applicant he did not build or improve for the purpose of sale.). S_SB RSB CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance O 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 builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Lender's Name Contractor's License Law.). Lender's Address O 1 am exempt under Sec. B. 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 WORKERS' P of this county to enter upon the above-mentioned property for inspection purposes. COM ENSATION DECLARATION. I hereby affirm that I have a cerhflcate of consent to self -Insure, or a certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. C.). Policy No. Company O.Certifiecopy is hereby furnished. O Certified copy is filed with the City Building Inspevction Department or City, ( Department. Dat/%_/ 1 i i' j�6 ApplicantX �f�o:cw" ��—IF �F APPLICANT NAME ADDRESS CITY/COMMUNITY/STATE/ZIP A/1 Cj.,'y'J.J JOB SITE ADDRESS/SPACE CITY/COMMUNITY/STATE/ZIP BON PAG PRC C TWN RNG SE S TRACT LOT- ✓� j0, { - MOD SB I TRACT NAME OWNER NAME IL. F, MI) , CONTRACTOR -FIRM NAME ADDRESS�M CITY/COM'MMUUNNIITY/STAATE/ZIP PHONE a/% LICNC N ARC/ENG FIRM NAME ADDRESS CITY/COMMUNITY/STATE/ZIP, - - PHONE M . LICNC N ' USE OF PERMIT BL ZON L FSB -' SSB S_SB RSB * OFC e ZONE ORD M LOT SZ END SIDE . Arrow Printing 250/1-83 White:'Finance Canary: Assessor , r 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 Duinta 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 1}420103 D TE�//// f i �✓-l/.�i/,7��® .r's`a�ld✓✓i' ��,/�,��"C/.-,rte +��/%�.i1/i �i x.•+5.4+ ��[./i/J IRA.¢'�' APR 2-21983 C64 oUt a Qi untA & .. TOTAL - EE•. FEE-- ✓� j0, { f VALUATION Pink: Applicant Tag: Bldg. Dept. t 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. ❑ NPN ADDITIONAL INFORMATION SEWAGE SYSTEM SIZE & LOCATION 11 Exterior Lath 12 Internal Lath 12A Drywall 13. Finish Grade INSULATION Thick R 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 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