RER (0765)53220 Avenida Martinez
0765
PERMIT APPLICATION
City of La Duinta
Department of Building and Safety
This. permit becomes void i1 work not commenced within 180 days from date of issuance. OR, if work has been suspended or abandoned for period of 180 days.
r - r
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I.arn 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
Lic. Number
Date Contractor
OWNER -BUILDER DECLARATION: I hereby affirm that I 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 a signed 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 heis 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, avid 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 improvemni is sold within one year of completion, the owner -builder will have the burden of proving that
r he did not build or improve for the purpose of sale.).'
O 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.).
yD I am tempt under Sec. : B. B.P.C. (Attached Certificate). .
`!Date • % i ' 1 A L Owner -
WORKERS',COMPENSATION DECLARATION: I hereby affirm that I have a certificate of'consem to self -insure, or a
oertilicaia of Workers' compensation Insurance , or a'certilied copy thereof (Sec. 3800. Lab. C.).
Policy No. .f / Company.
O Certified copy is hereby furnished.
❑ Certified,copy is filed wilh'Ihe City Building Inspection_ Department• or City ' _Department.
Date Applicant
APPLICANT NAME (L, F, MI)
,'
ADDRESS /.
CITY/COMMUNITY/STATE/ZIP
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JOB SITE AOORESS/SPACE '
-,)OC-) 1XAF .
CITY/COMMUNITY/STATE/ZIP
BOK
PAG
PRC
C
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TNM
FIND
SE
S•
TRACT
LOT
TOTAL
FEE
S
MOD
SB
TRACT NAME '
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME '
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 1
LICNC 0
ARC/ENG FIRM NAME • • -
ADDRESS
CITY/COMMUNITY/STATE/ZIP '
PHONE 1
LICNC
-
USE OF PERMIT
BL
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I ZON
FSB
SSB
SSB
RSB
OFC
. ZONE ORD I
LOT SZ
END
SIDE
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE:' This section need not be completed if
-the permit is for one hundred ($100) o. less. I certify that in the performance of the work for which this permit is
issued, I shall not employ any person i n any manner so as to become subject to the Workers' Compensation Laws of
California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become 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:
M hereby certify that no excavation five (5) or more feet in depthinto.which a person is required to descend, w ill'be
made in connection with -work authorized by this permit, and that no building structure, scaffolding; falsewoik, or
demolition'or dismantling thereof; will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341, Tille8,
C.A'.C.)
.❑ As•owner-builder,'I will.mot employ anyone to do work which would require a perinit.from the Division of
Industrial Safety, as noted above, unless such person has a permit -to do such work from that division.
O.Divisioq of Industrial Safety Permit No
'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 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: 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 Ouinta 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 ;I1./ t y
r
11 lul
TOTAL
FEE
S
BLDG. DEPT. VALUATION 7",,a,:J
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 Fite Wall
42
Commercial Hood
10
Fireplace P.L.
❑
43
Final
10A
fireplace T.O.
❑
NOADDITIONAL 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
PSL
STREET NAME
PA
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final