0352 (RR)t PERMIT APPLICATION
I ' City of La Duinta
i Department of Building and Safety ,
iThis 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. e 1 >
. . • • r•
• 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 Sof 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'CompensalionLaws of
j and effect.
J
California. � /1-1
%cr
License Class Lic. Number
Date Applicant if i, / fTrji-c—
RNG
SE
Date ^ ' Contractor �. V
•r _ N0310E 0 APPLICANT: df after making this Certificale of Exemption, you shot' ld become subject to the Workers' • .
OWNER•BUILDER DECLARATION: I hereby 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.,
be deemed revoked.
following reason (Sec. 7031.5. Business and Professions Code: Any city.or county which requires a permit to -
A/
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
suchpermittofileasignedstatement that -he is licensed pursuant to the provisions of the Contractor's License Law
01 hereby certify that n 6 excavation five (5) or more feet in depth'into which a person is reguired to desce4, will be
' (Chapter 9 (commencing with section 7000) of Division Sof 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, falsework, or",
. therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit_,,,- `.�
.demolitionOdismantting thereof, will be more than thirty -six -(36) feet high: (Chap 3.2, -Grp 2, Art 2, Sec 341, Title 8, •
subjects the applicant•to a civil penalty of not more.than five hundred dollars ($500.): 6:urs•
C.A.C.) - ' ' 1 "
o' 1, 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 would require a permit froOthe 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 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
❑.Division of Industrial Satety�Permit No.
I through his own employees, provided that such improvements; are not intended or offered for sale. If, however, the
_ ,
building or improventnt is sold within one year of completion, theowner-builder will have the burden of proving that
Date Applicant
he did not build or improve for the purpose of sale.).C, ,•
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance '
0 I, as owner of the property, am excufsively 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 contractor(s) licensed pursuant to the
RSB
Contractor's License Law.). . •
Lender's Address
0 1 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. l agree to comply .wit h all
Date " ' Owner
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., "
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or. a ..
A't t I W k ' Co ensation Insurance :ora certified co thereof (Sec 3800 Lab C ) '• -
-
ce I Ica e o or ers mp u pt'
Policy No. Company,
O Certified copy is hereby furnished.. -
0 Certified copy is filed with the City Building Inspection Department or City Department.
Date Applicant
APVLIC��ME(�F. MI)
ADDRESS ,!
CITY/COM MUNNII TTY/STATE/ZI P -
JOB SITE AOORESS/SPACE -
CITY/COMMUNITY/STATE/ZIP
BOK
PAG
PRC
C
'"' -
TWN..
RNG
SE
S
TRACT
LOT
A/
MOD
SB
TRACT NAME
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE A
LICNC 4
ARC/ENG FIRM NAME '
ADDRESS '
CITY/COMMUNITY/STATE/ZIP '
PHONE 11
LICNC I1
USE OF PE MIT
BL
ZONFSB
SSB
-8
!I
RSB
OFC.
-� ZONE ORD 6-
LOT SZ
,.
END,
SIDE'
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 Duinta 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 T DATE
A/
"TOTAL
FEE
n
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
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.
❑
NPO'N ADDITIONAL INFORMATION
-
SEWAGE.$YSTEM SIZE & LOCATION
11 Exterior Lath
12. Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
Value'
7A Walls (Batts)
126 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 P/L
STREET NAME -
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final