0649 (SFD)PERMIT APPLICATION
City of La Duinta
Department of Building and Safety
78-�5 9'U C 6'
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
I • ' -
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 r
(commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in -full force' '
issued, IshaO:not employ any person in any manner so as to become subject tothe Workers'CompensationLaws of)
and effect.
California.
License Class Lic. Number
Date Applicant
Date Contractor r.
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 the Contractor's License Law for the+
4 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.�'
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•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 ofth'eContractor's License Law
0 1 hereby certify that no excavation five (5) or more feet in deptninto which a person is requiled 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 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 permit
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3:2, Grp'7 Art 2, Sec341, Title8:
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): - *-.dPt:•
C.A.C.) P '
❑ 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-
fstructure
structureis 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
+
through his own employees. provided that such improvements are not intended or offered for sale. If, however, the
Division 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 Applicant
he did not build or improve for the purpose of sale.). %,
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agencyfor the performance
O 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 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—
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 Owner
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
LOT SZ
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 '.
.
Certificate of Workers' Compensation Insurance , or a certitied'copy thereof (Sec., 3800. Lab.. C.).
Signature of Applicant or Agent Date
Policy No. 6 j Company .'
0 Certified hereby furnished. f
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that'
'the is I laws to buidling
copy Is �!
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information given correct. agree to comply with all state and county ordinances relating
construction, and authorize a'representative of the City of La Duinta Department of Building and Safety to enter
11 Cer ified copy'is�filed with+ttlie City Building Ins ec Ion Department or City —•+�'�Department.
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upon the property for which I have applied for this permit for the purpose of making inspections.
Date Applicant
Signature of Applicant or Agent Date
APPLICANT NAMtE..(L. . MI(
ADORESS�
Y/COMUNPTY/STATE/ZIP
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CIT`M
JOB SITE jADDR ESS/SPACE
CITY/COMMUNITY/STATE/ZIP • ' , ' -
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TRACT NAME
OWNER GNXME.(fF:�1)?� / y......
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP '
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ADDRESS
C ITY//COM MUN I TYATAT E/ZI P
PHONE •
LICNC N
USE OF PERMIT
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SSB
SSB
RSB
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END
SIDE
Print Applicant/Agent Name
APPUPFIMT (✓f/J/./ �� wM,! ! �✓G! ��7�/✓�,••(� ,ter
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TOTAL
FEE •
r VALUATION
E�LDG. 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.
❑
NPON ADDITIONAL INFORMATION
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SEWAGE SYSTEM SIZE & LOCATION
-721
11 Exterior Lath %✓�
12 Internal Lath
12A Drywall ,2�(��/
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING APPROVALS
15 Ground Plumb 202 ' /1'
16 Water Piping
17 Rough Plumb
18 Vents
19 Sewage Disposal oia
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 P)
-
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final