0599 (BLCK)11
PEBMIT APPLICATION
City of La Duinta
Department of Building and Safety
This permit.becomes void it work not commenced within 180 days from date of issuance, OR; if work has been suspended or abandoned fora period of 180 days. . -- '
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'CERTIFICATE OF EXEMPTION FROM WORKERS' COMPEN;ATION INSURANCE: This section need not be completed if
LICENSED' CONTRACTORS DECLARATION: I hereby affirm that 1 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 3of the Business and Professions Code, and my license is in full force
issued; I shall not employ any person in any mannerso Esto.become subject tothe Workers' Compensation Laws of
and effect. 1-1-
California.
.License Class Lic.,Number %7��
Date Applicant
7� r
Date Contractor �p�aA , �' °' % ��: :.
,. t..NOT.ICE TO APPLICANT: If, after making this Certificate of Exemption, you should 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 `orthwith comply with such provisions or this permit shall
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following reason (Sec. 7031.5. Business and Professions Code: Any city or county .which requires'a permit to
. be= ,evoked.
m "
• construct, alter, improve, demolish, or repair any structure, prior -to its issuance, also requires the applicant•for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law
01 hereby certify that no dxcavation five (% or more fee. in depth intb which a person is reqbired to descend,will be
(Chapter 9(commencing with section 7000) of Division 3 of the Business and Professions Code) or th'atheis exempt.
• made in connection with work authorized by this permi .. and that no building stiucture, scaffolding, falsework, or
therefrom and the basis for -the alleged exemption:Any violation.of Section 7031.5 by any applicant fora permit;;
demolitionor dismantling 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.): w
C.A.C.)
0.1. as owner of the property, or my employees with wages as their sole compensation, will do the work, and the.
❑ As owner -builder, I will not employ anyone to do work which would require a permit from%he 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 Iles 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--'
4
-through his own employees, provided that such improvements are not intended or offered for sale. If, however, the ''
.0 Division of Industrial Safety Permit No.
building orimprovemntissold within one year ofcompletion, the owner -builder will have the burden of proving that -
Date' Applicant
he did not build or improve, for the purpose of sale.). .,
CONSTRUCTION LENDING AGENCY: I hereby affirm thatthere is a construction lending agency for the performance
❑ 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 contractor(s)licensed pursuant to the '..
SSB
Contractor's License Law.). -.
Lender's Address
❑ 1 am exernpt under Sec. B..B P.C. (Attached Certificate). •
I.certify that I have read this application and state.that :he above information is correct. l agree.to.complywith,all
Date ` Owner
city and county ordinances and state laws relating to beilding construction: and hereby authorize representatives --
" LOT SZ
of this county to enter upon the above-mentioned pro rerty for inspection purposes. y
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a
END.:
' certificate of Workers' Compensation'lnsurance : or a,certitied copy thereof (Sec. 3800. Lab: C.). c,
Signature of Applicant or Agent Date 4'
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify'I have read this application and state that + '
. ❑ Certified'copy is hereby turnished. - .. _
.. the information given is correct. I agree to comply will all state laws and county ordinances relating to buidling
,-,.o Certified copy is filed with the City Building InspectionDepartment or City- ' Department.
construction and authorize a'representative of the Ci y of La Duinta Department of Building and Safety to enter '
upon the property for which I have appliedfor this pe -mit for the purpose of making inspections.
Date Applicant
Signature of Applicant or Agent Date
APPLICANT 25ME(L:,F,,C)I, )h1__ '
CITY/C.CCLLOM MUN ITY/STATE/`I P '
C. �fHG N le--- C
JOBSITEI ADDR SS/SPACE
CITY/C�OM!UNITY/S. ATE/ZIP - - -
BOK
PAG
PRC
C
TWN'
RNG
SE
S
TRACT -
LOT
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MOD
SB
TRACT NAME
OWNER JIIjMj(L. F. MI)
CONTRACTOR -FIRM NAME
ADDRESS'
CITY/COMMUNITY/STATE/ZIP .. - ..
PHONE, •i O 9�s
sly- .J
c'
UCNC
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE •
LICNC •
[i/. S O
USE OF PERMIT
BL'
ZON
FSB
SSB
SSB
RSB
OFC "
ZONE ORD • �.,
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END.:
SIDE '
Print Applicant/Agent Name ' o
APPL/PRMT
iQd /ti t'
0/`f 4r OAJ L / /l./,e
r FAJ C
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TOTAL ` '• '
FEE •
[i/. S O
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.
❑
3� Final
10A
Fireplace T.O.
❑
OP'N ADDITIONAL INFORMATION
NO.
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywalls/2%
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
12B 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
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