0575IIIIIIIIIIIIIIIIIIIIIIIII 44
IE
PERMIT APPLICATION
City of La Duinta
Department of Building and Safety
x/020 .,va-i-
• 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 ff
the permit is lor•one hundred ($100) 0. less. 1 certify that in the•perlormance 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^
LICENSED CONTRACTORS. DECLARATION: I hereby alIirm'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 tic' Number
' Date •
Contractor • •
OWNER -BUILDER DECLARATION: 1 hereby affirm that 1 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 aligned statement that he is licensed pursuant to 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.):
.0 I. as owner of the property. or my 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. It, 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.). , . . .
0 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.). • . .
• 0 1 am exempt under Sec. • B 8 P C (Attached Certificate). '
Date Owner
`7 WORKERS' COMPENSATION DECLARATION:• I hereby affirm that I have a certificate of consent to self -insure, or a
l certificate of Workers' Compensation Insurance . or a certified copy thereof (Sec. 3800. Lab:. C.). • •
• Policy No.. Company
0 Certified copy is hereby furnished. •
0 Certified copy is filed with the City Building Inspection Department or City ' • Department.
Date • Applicant
AP A�
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TRACT NAME
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME
ADDRESS
-
CITY/COMMUNITY/STATE/ZIP
34/7-6 2
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ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N
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USE OF PERMIT
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Date 1'24 Applicant
NOTICE TO APPLIC NT: If, after making this Certificate of:E�you should 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 n b excavation five (5) or more 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 building structure, scaffolding, talsework, or
• • demolition or dismantling thereof, will be more than thirtysix (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec 341, Title8,
C.A.C.) .. u•:.
•
• 0 As ov ner-builder, I will not employ anyone t� do work which would require a permit from the Division of
Industrial Satety, as noted above, unless such person has a permit to do such work from that division. '
0 Division of Industrial Satety.Permit No.
Date Applicant '
CONSTRUCTION LENDING AGENCY: 1 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 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: )'certify I have read this applicationand state that
the information given is correct. I agree to comply with all state.laws and county ordinances relating to bufdling
construction, and authorize a representative of the City of La Quints Department of Building and Satety 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
IIS 7 5 /7:34.4i
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BLDG. DEPT.
VALUATION
/.SSo. D d
NO.
OPERATION
DATE
INSPECTOR
NO.
OPERATION
DATE IINSPECTOR
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'
ir07/lfS"
Thi
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. I.
NO.
O
ADDITIONAL INFORMATION
�7 �/ �i
/t : ,,i �/o7 //G ef 7/4'(.
.
.
SEWAGE.SYSTEM SIZE & LOCATION; _
11
Exterior Lath
12
.Internal Lath .
12A
Drywall
.
13
Finish Grade
.
INSULATION
Thick
' 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 jest
25
Final
Tank •Pit L. Line
REAR OF PROPERTY LINE
.ELECTRIC APPROVALS • - .
26
Power Pole
P/L
P/L
•
27
Conduit
•
28
Service Entrance
29
Wiring
29A
Grounding Wire
298
Bonding
30.
Fixtures
•
31
Service
32:
Final
'
STREET NAME
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