COMB (0653)APPL/PRMT �l 9 S 3
ADDRESS T � fOG�// VDl �//
Kr 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 aperiod of 180 days... '
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CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if .
LICENSED CONTRACTORS DECLARATION: I. hereby affirm that I. am- licensed' under provisions of: Chapter, 9, +
' the permit is for`one hundred -($100) 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 mannerso.as to become subject to the Workers' Compensation Laws of. '
and effect. - -
California.
_License Class- - Lici Number
Date Applicant
Date Contractor =• {". -
NOTICE TO APPLICANT: If, after making this -Certificate of Exemption, you should become subject to the Workers'
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OW NER-BUILDER DECLARATION:: I hereby affirm that I am exempt from the Contractor's License Lawlor the �'•,
: Compensation provisions of the Labor Code,.yottmust forthwith comply with suchprovisions or this permit shall . -
be deemed revoked.
following reason (Sec. 7031.5. Business.and Professions Code: Any city or county which requires a permit to*
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construct, alter, improve: demolish. or repair any structure, prior -to its issuance: also requires the'applicant tor-
DIVISION OF INDUSTRIAL SAFETY'PERMIT CERTIFICATION:
r- such permit to file a signed statement that he is licensed pursuant totheprovisionsofthe Contractor's License Law _ . •
.; 01 hereby certify that no excavation five (5)ormore feet indepth intowhichaperson isrequired todescendrwillbe,.
(Chapter 9 (commencing with section 7000) of division 3 of the Business and Professions Code) or that heisexempt -
inade m connection with work authorized by this permit, and that no building'structure, scaffolding, falsework, or - ,
'wherefrom and the basis for.the.alleged exemption 'Any violation of Section,7031,5.by anyapplicanPfor apermit .-
demolition ordismanthrig thereof will be more than'thirty-six (36) feet high: (Chap 3.2, Grp 2, Art 2. Sec341; Title8.
subjects the applicant to a civil penalty of not more.than five hundred dollars ($500.).
' C.A.C.) • ' ';
CY I. as owner o1 the property or my employees with wages as their sole compensation, will do the work, and the :
17 As' owner -builder; I will'not employ -anyone to do -work which would're4ke a'permit•from the. Division of • -
structure is not intended or offered for sale (Sec. 7044, Businessand Professions Code: The Contractor's License
Industrial' Safety: as noted above: unless such' person hasa permit to 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.
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through his own employees, provided that such improvemedtsare not intended or offered for sale. If; however, the
❑,Divisions of Industrial Safety. Permit. No..
building or improvemnt is sold within one year of completion, the owner -builder will have the burden of proving that ..
'Date -i Applicant
he did not build or improve.for the purpose of
CONSTRUCTION LENDING AGENCY:. I hereby affirm'that there is a construction lending agency for the performance ".
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:3097; Civ. C.): '
- 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 contractors) licensed- pursuanGto the
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Contractor's License taw.).... - L. ..
Lender's Address'
P' Pam exempt under Sec. ' rB. 8•P.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 -
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.er n • _ .. - .-a•.. -
^' n
Date Ovi
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 purposes^- .
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I,have a certificate of consent to'selPinsure, ora
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certificate.of-Workers' Compensation Insurance',,or a certified copy thereof (Sec: 3800. Lab. C;);',
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Signature of Applicant or Agent Oate
r,POlicy.No.' Company
mss- :'.
'•',CERTIFICATE OFCOMPLIANCE AND AUTHORIZATION OFENTRY: Icertily'Ihavereadthis application and 'statetnat '
' O Certified copy is hereby; furnished.
the information given is correct: I agree to comply with all state laws and county, ordinances relating to_buidling
' O Certified•Lropy is tiled wuh the.City Building Inspe`etion.Departrt' nt or City �' ` Department
" construction; and authorize a representative of the City of la Duinta Department of Building and Safety'to enter.. .,
upon for applied for '
• 2,.±s!• •.
.Date Applicant `�
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the property which I have this permit.for the purpose of making inspections. > :-
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Signature.ot Applicant or Agent Date
Print Applicant/Agent Name
APPL/PRMT �l 9 S 3
ADDRESS T � fOG�// VDl �//
C/r°if%gsoo� T.�°
JOB SITE.A�DRE7�E�,
CITY/COMMUNITY/STATE/ZIP
101-140—
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APPL/PRMT �l 9 S 3
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R IV ED
R 2t 1984
TOTAL"
'A FEE.
VALUATION
BLDG. DEPT.
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
L�
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
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SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick Value
7A Walls (Batts)
123 Ceiling (Batts)
12C Ceiling (Blown)
14 Ficial
PLUMBING APP OVALS
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 P/I
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final