0641 (RPL)PERMIT APPLICATION •• �jj ��
City of La Duinta V
.f'
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 pjriod of 180 days
117
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSALON INSURANCE: This section need not be completed it' '
LICENSED CONTRACTORS' DECLARATION: f hereby affirm that -1 am.licensed, under provisions of Chapter 9
the' permit is for one hundred (5100) o. less: I'certify that i c the performance otthe 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; Ishall not employ any person inany.mannersoas Ic become subject to the Workers'Compensation Laws of
and effect.
California.
License Class Lic. Number
Date Applicant
Date -Contractor
s,+ NOTICE.TO APPLICANT: If, after making this'Certificateof Exemption, you should become subject to the Workers' .
'OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's LicenseLaw 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
construct; after, improve, demolish, or repair any structure, prior to its issuance,.also requires the applicant for
..DIVISION OF INDUSTRIAL SAFETY.PERMIT CERTIFICATION:
such permit lo,file asigned statement that he is licensed pursuant to the provisions of the Contractor's License Law
01 hereby certify that no excivation five (5) ormore feet irsdepth 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
1*1rnade in connection with work'authohzed 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 dor a permit ,
!';: "demolition or dismantling thereof; will be more than thirty-5ix (36) feet high: (Chap 3.2, Grp 2 Art 2, Sec341, Title B,
subjects the applicant to a civil penalty of not more than five hundred dollars (5500.):
C.A.C.) "
- O 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 wcrk which would'requ4e a permit from the Di6sion 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 hEs a permit to do such work from that division.
Law does notapply to an owner of property who builds, or improves thereon, and who does such work himself or
. .• • t
through his own'empfoyees, 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.). c
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
A Las 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; Cv..C.). •'i+
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
.O.I am'exempt under Sec. B. 8 P.C. (Attached. Certificate).
, . I certify that 1 have read this application and state that the above information is correct. I agree to comply with all.
Date ar Owner ' '
city and county ordinances and state laws relating to bui ding construction, and hereby authorize representatives,
of this county to enter upon the above-mentioned propetiy for inspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to sell -insure, or a
certificate of Workers' Compensation Insurance , or a'certified copy thereof (Sec. 3800. Lab:•CJ.
Signature of Applicant or Agent Date
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF'ENTRY: ] certity I have read thisapplication and statethat
❑ Certified copy is hereby furnished. ; '-
the information given is'correct. I agree to comply with ail state laws and county ordinances relating to buidling
/
O Certified copy is.filed withlhe City Bu ilding,lnspection Oepartmentlor City ` D partment.
-�
;p 17 7
construction, and'. uthorize a *representative of the•Citp of La Ouinta Department of Building and Safety to enter'
upon the_propertyLoi which I have applied for this pemitfor the purpose of making inspections.
�! �', , ,2 ,,) j
Date Applicant
117
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CITU�OM/ `MUNJTY/STAT,E/ZZI'G
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JOB SIT
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CIUNI TY/STATE/ZIP .
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MOD
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TRACT NAME
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME -
ADDRESS
CITY/COMMUNITY/STATE/ZIP
TY
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ARC/ENG FIRM NAME ..
ADDRESS -
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC 0
'
USE OF PERMIT -
81.'
ZON
'FSB
SSB
SSB
RSB
OFC .
' ZONE ORD •
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END
'SIDE
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMT fl 9 4 1 y9/,W 9 W
TOTAL ".'•
FEE •
r- a,�,� '
VALUATION
BLDG. DEPT.
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION DATE INSPECTOk
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 Waif
42
Commercial Hood
10
Fireplace P.L.
❑
43
Final
10A
Fireplace T.O.
❑
NON ADDITIONAL INFORMATION
/44z
-
1,17)
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
t2 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick
Valualu e
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
STREET NAME
P/I
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final