BLCK (001209)PERMIT APPLICATION
City of La Duinta
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. _
ADDRESS 51-066, Avenida Mendoza.
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if '
' LICENSED CONTRACTORS 'DECLARATION: .1 hereby affirm that I am licensed .under provisions of Chapter 9
the permit is for.one hundred. (S100)'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 any manner so as to become subject to the Workers'Compensation Laws of .
and effect. _
California. '
License Class Lic. Number
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 herby 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, priorrto its issuance, also requires the applicant for .
DIVISION.OF.INDUSTRIAL SAFETY PERMIT CERTIFICATION:
such permit to file a signed statement thathe is licensed pursuant to the provisions of the Contractor's License Law
0. thereby certify that no excavation live (5) or more feet in depth into which a person is required to descend. 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, fatsework, or
therefrom.and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
demolition or dismantling thereol, will be more than thirty-six (36) feet high: (Chap 3.2, Grp 2, Art 2, Sec341, Title 8,
subjects the applicant to a civil penalty of not more than five hundred dollars (5500.):
C.A.C.)
0 I, as owner of the property. or my employees with wages as their sole compensation, will clothe work, and the .
0 As owner -builder, 1 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 permWto do such work from that division.
Law does not apply to an owner of property who builds, or improves thereon, and who does such work himself or
CITY/COMMUNITY/STATE/ZIP -
through his own employees. provided that such improvements are not intended or offered focsale. If, however, the
0 Division of Industrial ,Safety Permit No.
building or improvemni is sold within one year of completion. the owner -builder will have the burden of proving that
Date Applicant
he did.nof build or improve for the purpose of sale.).
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lehding'agency for the performance
0 I, as owner.of the property, am exculsively contracting with licensed contractors to construct theproject(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
Lender's
builds or improves thereon. and who contracts for such projects.with a contractor(s) licensed pursuant to the
. ,Name
Contractor's License Law.).
'Lender's Address
A� /
❑ I am exempt under Sec. > •�/� `' •' . B..BAP.C. (Attached Certificate).
I.certify that I have read this application and state that the above information is correct. l agree to comply with all •�:
Date Owner ' �hLL�' // �
city and county ordinances and state laws relating to�building construction, and hereby authorize representatives
Kinsure,
of this county to enter upon the above-mentioned property for inspection purposes:
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to se ora.
END
certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800.1ab.T.). %—"
Signature of Applicant or AgentDate
Policy No. Company.
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:Icertify Ihave7eadthis application and state that ' '
0 Certified copy is hereby furnished. +. r ..•
the information given is correct. Vagree to comply with all state laws and county ordinances relating to buidling
I O Certified copy is filed with the City Building Inspection Department or City ' Department.
construction, and authorize a'representative of the City of La Duinta Department of 8uilding and Safety to:enter
'
F Date Applicant
upon,the property for which I have applied for this permit for the purpose of making inspections.
4 '
Signature of Applicant or Agent Date
APPLICANT NAME (L. F. MI) FZ11 le Nigg "
ADDRESS 51-066, Avenida Mendoza.
CITY/COMMUNITY/STATE/ZIP L Quin a, ' fir.92253
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JOB SITE ADDRESS/SPACE • v' •° .
CITY/COMMUNITY/STATE/ZIP Ia' ��+�/ CA 92253
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OWNER NAME (L. F. MI) %jYlt Ucar'yt - -
CONTRACTOR -FIRM NAME
,ADDRESS above .
-
CITY/COMMUNITY/STATE/ZIP above
PHONE 0 564-3321'
LICNC 0
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE •
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SIDE
Print Applicant/Agent Name
APPL/PRMT n nl 7 2"TE-85 E •
Pemit to cmist =t 62 M ft. of wood
fence.- Dropped levels starting at
6 then 5 and: then 4 ft. high as- per
approved pis • I
}
G 'n�
V� I
TOTAL
FEE •
15. 00 '
BLDG. DEPT. VALUATION 500.00
• '
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.
❑
NON ADDITIONAL INFORMATION
EC qqpp
r
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 Waier 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
298 Bonding
30 Fixtures
31 Service
32 Final