SATT (0073)LICENSF—_b CONTRACTORS DECLARA710
(co mine riCJ991 fir SEctmn.70001 of 01vi
and eflect
License class LIG Number
Date Conlractor
OWNER -01,111 -DER VULARATIOW I hereby affirm Thal I am exempt from the ContraCtur s License Law for the
lotlowirrg reason (Sec. 7031.$, Btislrress and Professions Cade: Any oily Or county which lecluires a permit to
construe'• alter, I nl prove, demolish, ur repair. any sl facture. pilar to Its Issuance, al go requlre5 the appllGanl for
such Pe r rnl l to El le a slg ned slater enl Th at h e is lice hied pu r 5u ant to lila p rov is Ions of th a Cont racto i s L lc on se Law
(ChaplErr 9 (commencing with section 700G1 of Division 3 of the Ruslness and Professions Cade) or that he is exempt
therelro m and the basis fer the alleged exemption. Any vl¢let Iarl of Section 7031,5 by any applItant for a permlt
SUbjects tho aPip IPcanl fo a civil penalty of not more than live hundred dollars (SW -
❑ 1: as owner of t W property, or my employees with wages as their sole campansation, w111 do the work, and the
struciur6 is not intended of offered for set a{Seo- 7044, Business and Professions Coda: The Contractor's License
Law does not app iy 10 an owner of Proyerly who hu Ids. or Improves therm n, and who does Uch W ark hi rhsN f or
through his own employees, provided Ihat such Imprnvernenl5arenot Intended or offered for sale. If, however. the
building arra'provremntissoIdwlIhlnanoyea rOf"inPI ion.theowner-buiiderwit Ihave the hurdenplprovIngthaI
he did not build 0r Improve for the purpose of sale:).
C3 I, as owner of the property, am exculsivaly contracting with licensed contractors to construct the project (Sec.
7D44 Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or Improves [hereon, and who contracts for such projects with a cdnlractor(s) licensed pursuant to the
Coniractot's License Law,l.
❑ I am exempt under Sec. B. 8 P.C. (Attached Certificate).
Date Owner
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.).
Policy No- Company
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the City Building Inspection Department or City Department,
Date_ Applicant
PERMIT APPLICATION
City of La puinta
Department of Building and Safety
This permit becomes void if work nor commenced within 180 days from date of issuance, OR, it work has been suspended or abandoned for a period of 180 days,
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not becompleted i
N: I hereby affirm that I am licansed under provisions Di 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
Sion 3Of[heBusiness and Professions Code, and my license is in full force issued, I shall not em ploy Y anypersoninanymannersoasfobecomesubjectfofheW¢rkers'CompensationLawso
California.
APPLICANT NAME (L, F, MI) _��
ADDRESS .•f t.r3� 1 -1
O ITYICOMMUNITY,5TIATE/Zi rP
JOB SITE ADDRESS/SPACE
C I TV/COMM UNITY/STATE/ZIP
eOK PAG PRC
C TWN
RNG SE S
TRACT LOT MOD SB
TRACT NAME
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME
ADDRESS
D, ITYM,OMMUNI7YrS TA TE/ZI P
PHONE M
LICNC M
ARC/ENG FIRM NAME
ADDRESS
OI TYICOMM UNIT YISTATEJZI P.
PHONE M LICNC M
USE OF PERMIT
BL
ZON
FSB SSB
SSB
RSB
OFC
ZONE ORD X
LOT SZ
END
SIDE
Applicant
NOTICE TO
ter making this
on, You should become
kers
Compensation Pprovisions offthe Labor Code, you lfmust forthwith pclomply with such provisions lorth sect to tperm phe ermit
be deemed revoked,
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
T hereby£erllf y that no excavation live (5) or more feet in depth into which a pwsdn is required todescend, will be
made in connection with work authorized by this permit, and thatno bullding structure, scaffolding. IMSework, or
demolitionordismantling thereof, will be more than Thirty-six (36) feel high..(Chap 3:8, Grp 2, Art 2,Sec341, Title B,
CAD)
As owner -builder, I will not employ anyone to do work which would require a permit from the Division of
Industrial Safety, as noted above, unless such person has a permit to do such work from that division.
❑ Division of Industrial Safety Permit No.
(late
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 }Jame
Lender's Ad
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 slats awerelating to building construction, and hereby authorize representatives
of this county to enter upon the above-inentioned property for inspection purposes-
Signature of Applicant or Agent Date
CERTIFICATE OF COMPL14NCE AW AUUiDRIZATION OF ENTRY. I certify I have read Visa ppflcatlffnand slate that
the informal ion given is correct. I agree to comply WI It, all stale laws and county ordinances rotating to buidilnq
constru£ti¢n- and authorize a representative of the City of LaUnta Deparlmenl of Ruifgin9 and Safety fe enter
irpon.the proporly for which I have applied for this permit lar W purpose or making tispedtipns.
Signature of Applicant or Agent
Date
Print Applicant/Agent Name — —
APPL/PRMT i .
DATE
"1SJ
eai»'i� 1,1=, �$
i �l,'7�I7G�S
Fee
N'Mnit FIM
c i aC iC t
b1Z..Li. rC..r_a.a t F,e
� r Fee
i — 1 ' AIrYLL IC,
OTAL .
FEE
1 V S
Arrow Printing 250/1-83 White: Finance Canary: Assessor Pink: Applicant Tag: Bldg. Dept. VALUATION I==
NO. OPERATION DATE
BUILDING APPROVALS
1 Set Back
2 Ftgs & Frms
2A Slab Grade
3 Steel
4 Grout Blocks
5 Bond Beams
6 Roof Deck
7 Framing
8 Vents
9 Garage Fire Wall
10 Fireplace P.L. D
10A f=ireplace T.O.
11 Exterior Lath
12 Internal Lath
12A Dryr:all
13 Finish Grade
„R"
INSULATION Thick Val uL,
7A Walls (Batts)
12B Ceiling (Batts)
12C Ceiling IBlown)
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
Watar Service
24
Gas Test
25
Final
26
Power Pole
27
Conduit
2g
Service Entrance
29
Wiring
29A
Grounding Wire
29B
Bonding
30
Fixtures
31
Service
32
Final
INSPECTOR
V I TH
ELECTRIC APPROVALS
NO. OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
33 Ventilation System
34 Plenums & Ducts
35 Furnace Compart.
36 Inlets & Outlets
37 Combustion Air
38 Compressor
39 Appl. Clearance
40 Fire Damper
41 Smoke Detection Device
42 Commercial Hood
43 Final
OP'N ADDITIONAL INFORMATION
NO.
SEWAGE SYSTEM SIZE & LOCATION
Tank Pit L. Line
REAR OF PROPERTY LINE
STREET NAME