BLCK (0483)52360 Avenida Madero
0483
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ADORE
'0061/1 I .f-l•
' ♦ PERMIT APPLICATION+ " -
,r City
of La Dumta
' - Department of Building and Safety
AG
PRC •
,. •• - • .4 This permit becomes void:il work not commenced within 180.days from date of -issuance, ORt if work has been suspended or abandoned for a period of.180 days: '... ..
• • - .. ;jr w. ., ..-.
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CERTIFICATE -OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not becompleteAif'''
LICENSED CONTRACTORS DECLARATION I -hereby affirm thatcl am licensed under provisions of ,Chapter 9 '~'
the permit.is'for one hundred ($100) o: less,* l certify that in the performance of the work for which this permit is
' (commencing with Section -7000) of*Divisiob 3of the Business and Professions Code, and my license is in full'force -'•
.: issued; I shallnot employ any person in any manner so as to become subject to the Workers'Cortipensation_Laws of
and effect.
California.
License -Class s Lic. Number
t
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 thata am exempt.from the. Law for the
:Compensation provisions of the LaborCode,you must forthwith comply with'such provisions, or this permit shall ^
10
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.tofileasigned statement that heislicensed pursuanttothe pravisionsoltheContractor's License Law -
OIhereby certifythat noexcavation five (5)or'morefeetindepthintowhictiapersonisrequired todescend,will be '•
(Chapter 9 (commencing with section 7000) of Division 3 of.the Business and Professions Code) or that heis exempt .. '
made in connection with work authorized by this permit, and'tnat no tiuifding structure, scaffolding, falsewdrk, or
' therefrom and. the basis lor.the,all eged exemption. Any violatian.ol'Section 7031;5 by any applicant for a permit ' •
demolition or dismantling thereof, will be"more`{ha6thirty-six (36) feedhigh. (Chap'3:2, Grp 2, Art 2; Sec341; Title8,
subjects the applicant to.a-civil penalty of notmore 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
0 As owner -builder, I will not employ.anyone to do work which wduld require a` permit from the Division of
• .structure is notintended 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 improveslhereon, and who does such work himself or
a •. ' ,
' tKiough his own employees. provided that such improvemedtsmre not intended or offered for sale: II; however; the
❑ Division pf Industrial Safety Permit No. ,
building or improvemni is soldNilhin oneyear of completion, the owner-builderwillhave the burden of proving that
Date' " '- ” Applicant- „
he, did not. build o. improve for the purpose of sale.). . .'
;': CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance Z
. 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. -3D97; Civ:.C.).-
r 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.,
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• • Contractor's License Law.).
Lender's Address
••0 I'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.) agree to comply with all • •. .
Owner . M
city -and county ordinances and state laws relating to building construction, and hereby authorize representatives
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of this county to enter'upon the above=mentioned property for inspection pu'rposes.'
WORKERS' COMPENSATION DECLARATION:' I hereby affirm that I have a certificate of consent to.self-insure; or a' .
• certificate of Workers' Compensation Insurance , or.a certified copy thereof.(Sec.'3800..Lab. C''):,". ' . ' •: • .'
'; 't : -'
Signature of Applicant or Agent Date . ..
Policy.No. Company, 1
•0 Certifjed-copy is hereby/furnished. s' -'. a J f
/.=
- :• CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY. I certify I have read Misapplication and state that '
'-. the information given is correct: I agree to comply with all state laws and county ordinances'relating to buidling
' )
construction, and auIhorizea.;re presentative of. the'City. of La Ouinta Dpparlment of'Building and Safety to enter
O'Certifled copy is filed with the City Building Inspection De art ent or.Cit Department
} ,1 /, • %
" f i' G
—.. upon property tor.which I have applied for -this permit for the purpose otmaking inspections. •.
Date ✓ plicant / 1.' .rr
•
Signature of Applicant or Agent Date
..
—
Print Applicant/Agent Name
APPU//C%%A N NA/ i1E (L: F. MI)
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ADORE
'0061/1 I .f-l•
CITY/COMMUNITY/STATE/ZIP -
JOB SITE ADDRESS/SPACE ,-
CITYY//COMMUNITY%STATE/LIP -
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'TRACT NAME .. '
OWNE NAME F. MI) •- - - .. -
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CONTR GOR -FIR ^NAME
♦ T.
ADDRESS .• - - '
CITY/COMMUNITY/STATE/ZIP .. . .. ..
PHONE 0 •.
LICNC •
zoa
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,ARC/ENG FIRM NAME '
ADDRESS -- -
CITY/COMMUNITY/STATE/ZIP' ♦ ,
PHONE N-
' LICNC Ir
- -
USE OF PERMIT _ . • - '
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SSB _
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ZONE ORD I,I,"
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SIDE
-VALUATION 0A j uCi
BLDG. DEP'T.... >
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V. T.
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TOTAL
FEE
-VALUATION 0A j uCi
BLDG. DEP'T.... >
NO.
OPERATION DATE INSPECTOR
NO.
OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1.
' Set Back
33
Ventilation System
2
Ftgs & Frms
S , T f''
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.
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UPN ADDITIONAL INFORMATION
NO.
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
P;L PSI
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final