0334 (SATT)PERMIT APPLICATION /]�
City of La Duinta 6
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 fw 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 ($100) 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 in any manner so is to become subject to the Workers'.Compensation Laws of
and effect. California.
License Class Lic. Number
Date" Contractor
OWNER -BUILDER DECLARATION: I hereby affirm•that I am exempt from the Contractor's License Law for the
following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit.to
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law
(Chapter 9(commencing with section 7000) of Division 3 of the Business and Professions Code) or that he is exempt
therefrom and the basis for the alleged exemption..Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more -than five hundred dollars ($500.):
❑ I. as owner of the property,.or my employees with wages as their sole compensation, will do the work, and the
.structure is not intended or offered for sale (Sec. 7044, Business and Professions,Code: The Contractor's License
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
building or improvemnt is sold within one year of completion, the owner -builder will have the burden of proving that
he did not build or improve for the purpose of sale.).
0 1. as owner of•the property, am exculsively contracting with licensed contractors to.construct the project (Sec.
7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves' thereon, and who contracts for such projects with a contractor(s) licensed pursuant to -the.
Contractor's License Law.).
O 1 am exempPunder Sec.' .8. 8 P.C. (Attached Certificate).
Date Owner
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: 3800. Lab. C,). '
Policy No. Company
O Certified copy is hereby furnished. -
O Certified copy is file with the City Building Inspection Department or City, Department. ,
Date //zi%� Applicantf'_
�AP^PLIC/A�.,N�T.�NyA�M�yE..(L, F+�Mni
ADDRESS
P. 0. BmC 780
CCOMMNITY/STTE2IQ .
la1fi;n/CA92253
JOB SITE ADDRES&SPACE
50-166Calla rma,�to
CITY/COMMUNITY/STATE/ZIP..a tumt�� 92.253
BOK
PAG
PRC
C
-• -
TWN.
RING
SE'
S
TRACT
1,196-1
YAS1
250,25
(7mistn=ticn Fen
moo
F-1
SB
31,25
TT�RA�AC�yTT�, NAME�,..^^ �s
Sm 'W j`>=a WYa '
OWNER NAME (L. F. MI)
CONTRACTORL.FIRM AME '
X3��Y.3�r $1Q.i1
P. ADDRESS U. E= 780
CITY/COMMUNITY/STATE/
TE/ZI 92253
PHONE*6554--1315
" M762
ARC/ENG FIRM NAME -
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 1
LICNC M
'
USE OF PERMIT
SteleF-my E. aUing
BL
ZON
FSB
SSB
ss8
RSB,
OFC
, ZONE ORD N.
1
LOT SZ
..
END
SIDE
Date Applicant
NOTICE TO APPLICANT: If, after making this'Certificatt of Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you mustforthwith comply with such provisions or this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 hereby certify that no excavation five (5) or more feb I in depth into which a person is required to descend, will be
made in connection with work authorized by this perm 1, and that no building structure, scaffolding, falsework, or
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp -2, Art 2, Sec 341, Title 8, .
C.A.C.)
❑ As owner -builder, I will not•employ anyone to do work which would require a permit from the Division of
Industrial Safely, as noted above, unless such person has a permit to do such work from that division.
.0 Division.of Inq slrial,Safety Permit No. .
Date Applicant -
CONSTRUCTION LENDING AGENCY: I hereby affirm tha- there is a construction lending agency for the performance
of the work for which this permit is issued (Sec. 3097 Civ. C.).
lender's Name
Lender's Address
I certify that I have read this application and state thaUhe above information is correct. I agree to comply with all
city and county ordinances and state laws relating to building construction, and hereby authorize representatives -
of this county to enter upon the above-mentioned prooerty for inspection purposes. '
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION Oi ENTRY: I certify I have read this application and state that
the information given is correct. I agree to comply -wit r all state laws and county ordinances relating to buidling
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 applied for'this permit for the purpose of making inspections.
Signature of Applicant or Agent Date
Print Applicant/Agent Name
. APPL/PRMT �) i.
10-19-83
P mit to car 3truct K, P -1--A
_-Uling
10431 tae
Pn=h
112 S* -1, M,
farm
422 Sq, M,
1.7=h. Rm
$ 31.00
Plan Cite,. Fe3
250,25
(7mistn=ticn Fen
335, 00
E1 atxical Ft -_A
31,25
S11 Fe
5.35
pi=,bing PC--
43450
P=p, FxW J-zm=nt
F= 450.00
TOTAL
FEE
o
BLDG. DEPT.
VALUATION "5 a",3 -,-,=
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
J Compressor
6
Roof Deck
-
39
Ap'p'l. 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.
❑
OP'N ADDITIONAL INFORMATION
NO.
'7111 / ���,/+7. of �. -� Fina'
�r SC. &I
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
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 /& 7A(
16 Water Piping
17 Rough Plumb
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
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 ,
r�