0732 (AR)I
,
' , • PERMIT APPLICATION
r 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 a period of 180 days. -
_
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 -($101) o. less. I certify that in the performance of the work for which this permit is
• (commencing with Section 7000) of Division 3 of the Business and Professions Code; and my license is in full force
issued, I shall not employ any person inany mannerso as to become subject to the Workers' Compensation Laws of
and effect.
California. •.
License Class Lic. Number
Date Applicant
Dale'- Contractor —
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, -you should become subject to the Workers' .
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from tlielContractor's License Law for the
Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall -
following reason (Sec. 7031.5. Business and Professions Code: Any city or county.which requires.a permit to
be deemed revoked.
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for • -
DIVISION OF INDUSTRIAL. SAFETY PERMIT CERTIFICATION: ..
such permit to file a. signed statement that he is licensed pursuanttothe provisions.ofthe Contractor'sLicense-Law,
.. - 01 hereby certify that do excavation five l51tir more feet in depth into which a person is required to descend, w ill be •.
(Chapter 9.(commencingwith section 7000) of.Division 3 of the Business and Professions Code) or that he is exempt •.
made in connectionv/ith work authorized by'this permit, and that no building structure, scaffolding, falsework, or
' therefrom and the basis for the alleged exemptien.,Any violation of, Secti67031.5 by any,applicanffor•a permit; ..
demolition or dismantling thereof, will be more than.thirty-six (36) feet high. .(Chap 3.2, Grp 2, Art 2; Sec 341, Title 8,
subjects the applicant to a civil penalty of not more than five hundiei .dollars ($SOOJ:
C.A.C.)
.O I. 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,from the 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,,
..,.,c .. s
through his own employees, provided that such improvements are not intended or -offered for sale: If, however, the ..
0 Division of Industrial Safety Pa,(mit No.
building or improvempt is sold within one year of completion, the owner -builder will.ha.ve the burden of proving that.
Date Applicant
he did not build o"improve for the purpose of sale). .
'
CONSTRUCTION LENDING AGENCY: I hereby affirm that.there is a construction lending agencyfor•the performance
ll7 I. as owner -of the property, ameexculsively 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 -
+
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. I agree to comply with all .
Date • ? ,i < Owner /%/
city and county ordinances and state laws relating to build ingconstruction, and hereby authorize representatives .'
1 ' . • I/ f '
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, ora
.
-' certificate of Workers' Compensation Insurance'.•or a certified copy thereof (Sec. 38(X1. lab. C.).
..Signature
of Applicant or Agent Date
Policy No. Company „ '
rtify l have read thisapplicationand state that
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: 16'
0 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 copy is filed with the City Building Inspection Department or City - u Department.
construction, and authorize a'representative of the City of la Ouinta Department of Building and Safety•lo.enter .,.
upoon the property for which I have applied for this permit for the purpose.of making inspections.: 'f
Date Applicant
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPLICANT NAME -(L, F, MI)
SGf1�G
.9"V1J,1 14 `ADDRESS
7-0 Co t/sT.ev�T - 97.s"
CITY/COMMUNITY/STATE/ZIP.
JOB SITE ADDRESS/SPACE '
CITY/COMMUNITY/STATE/ZIP
BOK
PAG
PRC
.,C'
- ,
TWN
RNG
SE
S
TRACT
LOT,-
MOD,
SB
-
TRACT NAME ••
OWNER NAME (L. F. MI) • '
CONTRACTOR -FIRM NAME - '-
ADDRESS -
CITY/COMMUNITY/STATE/ZIP .. ,. -
• .1
PHONE .
LICNC 1
,
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP .. -
PHONE.
LICNC0
s
USE OF PERMIT
BL
ZON
FSB
SSB
SSB
RSB'
-
OFC ..
�. ZONE ORD..
LOT SZ
END .
SIDE
APPVPRMT
7-0 Co t/sT.ev�T - 97.s"
4F .qD•O/Tio�t/ !!.s �E-F' t7o,�.E� oc��0
A -1:1 -CAV / T 4/y-5-0
EGCEcTi�'iG o ,
ECEIVE®
Yfl
TOTAL'
rF s `TOTAL'
- FEE
• ' . + VALUATION 3 Y 7;7,370,
'• - 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
7
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.
❑
NO
ADDITIONAL INFORMATION
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal 'Lath
12A Drywall
13 Finish Grade
INSULATIONic,
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
25Final
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
PSL 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