0313 (SFD)�,
ADDRESS � � ��� ��� • ��
^ RPPLICATION
_PERMIT
City of La Duinta r
-Safety
" Department of Building and '
BOK PAG }
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- This permit becomes void if work not commenced within, 180 days from date
of issuance. OR, if work has been suspended or abandoned to, a-peiri6d of days. �� • '. -
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CERTIFICATE OF EXEMPTION FROM WORKERS' COMPEtSATION INSURANCE: Ttiirsection neednot 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 I iatp-the performance"of the work for which.this permit is;
'.(commencing ' with Section 7000) 111 Division 3 of the Business and Professions Code, and my'license is in full force .
and effect.
issued, I shall not.employ any person in any manner sonsto'become subject to the Workers'Compen'sation Laws of •'
California.
License•Class Lic. Number
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. •' ✓Date C7/ ` ^• Applicant -
MOO
Date Contractor,- -
• NOTICE TO APPLICANT. If, after making this Certrticat, of Exemption, you should become subject to the Workers''
Compensation of the Labor Code, mus forthwith.comply with such or this permit shall
OWNER-BUILDERDEARATION:. I hereby affirm that Iain exempt from the Contractor's License Law for tffe
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provisions provisions you provisions
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be deemed revoked.
following reason (Sec. 7031.5,' Business and Professions Code:'Any.city. or county which requires a permit to
ADDRESS •• - .
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICA"'ION: . .
_ such permit to file a signed statement.that he is licensed pursuantto the provisions of the Contractor's License Law
0- 1 hereby'certily that Ab excavaition five (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 perm(, and that no building structure, scaffolding, falsework.br
• therefrom and.the basis for the alleged exemption.. Anyyiolation of Section 7031.5 by any applicant.fora permit '
'demolition?or dismantling thereii will be more than th:ay.siz (36pfe`et high: (Chap 3.2, Grp 2,.Art 2; Sei341,•Ti11e8; :.
subjects the applicant to a civil penalty of noYmore than five hundred dollars (S500.); • '
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• O. I, as owner of the ro ert ; or m emplo ees with wages as their sole compensation, will do the work, andthe
P P Y Y Y 9
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❑ As owner -builder, I will not employ anyone do",work which require•, permit from the Division of
structure is not intended'or offered for sale (See. 7044, Business and Professions Code: The Contractor's License
' Industrial Safety, as noted above: unless such perrsor 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
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Permit No.: �—
through his owmemployees, provided that such improvements are not intended or offered for sale. If, however, the � °
O Division of.IndustriaLSafei
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buildingocimprovemntissoldwithinone year ofcompletion. the owner -builder will havetheburdenolprovingthat
f(/Dete ."T Applicant -1 •�
he did not build or improve for the purpose of sale:).
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CONSTRUCTION LENDING AGENCY: I hereby affirm tha! there is a construction lending agency for the performance.
0.1, 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 doesnot apply to an owne&ol property who
Lender's,Name
'builds or 'improves thereon; and who contracts for such projects with a contractor(s) licensed pursuant to:the • •.
Contractor's License Law.). ' _. _.
Lender's Address
: ❑ Cam exempt under Sec. ' ` B.1 P.C. (Attached Certificate)..
.. I certify that I have read this application and state thafthe above information incorrect. I agree to comply with all., .
c. • `:. -
Date Owner
city and county ordinances and state laws relating to tuilding construction, and hereby authorize representatives.
*to
of this county enter upon the above-mentioned prooerty for inspection purposes. '
WORKERS' COMPENSATION DECLARATION: I herebyaffirm that I have a certificate of consent to self -insure; or a
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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 Agenf"• - '- •Date '.
Policy No. Company
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CERTIFICATE OF COMPLIANCE AND AUTHORIZATION 01 ENTRY: I certify I have read this application and state that
❑ Certified copy is hereby furnished.';!. •:
'the information -given is correct. I'agree to comply wiLl all state laws and county ordinances relating to b6idling
O' Certified copy is filed with the City Building Inspection` Department .&'City• Department.
construction, and authorize a:'representative of the City of La Ouinta Department of Building and Safety to enter
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upon the property for which) have applied for this pami'tfor the purpose•of making inspections. ..
Date Applicant
Signature of Applicant or Agent Date
^ Print Applicant/Agent Name
APPLICANT
� R (iy' MI'/`�FsCvt2
ADDRESS � � ��� ��� • ��
CITY/COMMUNITY/STATE/ZIP
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JOBBf°SIITE ADDRREESSSSfS'P'AC42—
CITU COMMUNITY/STATE/ZIP l ,.
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TRACT NAME • '
OWNER NAME (L. F. MI) .• • ' '
CONTRACTOR -FIRM NAME `�'�-'�,► - . '
ADDRESS •• - .
CITY/COMMUNITY/STATE/ZIP -
PHONE 01 - 1
cityof LaW
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ARC/ENG FIRM NAME ..
ADDRESS '
CITY/COMMUNITY/STATE/ZIP
PHONE a
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USE OF PERMIT '
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END
SIDE ,
APPL/PRMT �L A i1 ,
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cityof LaW
s' TOTAL"
FEE
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lVALUATION �Y�6
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
jD /02 X73
r
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.
❑
NADDITIONAL INFORMATION
O.
NO.
~
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath o7 _
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 7,
16 Water Piping
17 Rough Plumb J3
18 Vents
19 Sewage Disposal
20 Sewer 3
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 PiI
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance •
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final